Provider Demographics
NPI:1861620981
Name:OMOKHODION, OMOKHUALE (MD)
Entity type:Individual
Prefix:
First Name:OMOKHUALE
Middle Name:
Last Name:OMOKHODION
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3358 LAUREL WAY SE
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30080-4457
Mailing Address - Country:US
Mailing Address - Phone:248-390-0241
Mailing Address - Fax:
Practice Address - Street 1:2145 ROSWELL RD STE 60
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30062-0819
Practice Address - Country:US
Practice Address - Phone:770-672-6267
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-26
Last Update Date:2023-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA40788207P00000X
IL125-052067207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine