Individual
DR. OMOTAYO OLUSOLA FASAN
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MBBS
Contact information
Practice address
125 QUEENS RD STE 600, CHARLOTTE, NC 28204-3215
(980) 302-6600
(980) 302-6605
Mailing address
PO BOX 60447, CHARLOTTE, NC 28260-0447
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
2013-01292
NC
207R00000X
Internal Medicine Physician
MD433151
PA
207R00000X
Internal Medicine Physician
MT183411
PA
207RH0000X
Hematology (Internal Medicine) Physician
Primary
2013-01292
NC
207RH0000X
Hematology (Internal Medicine) Physician
MD433151
PA
207RH0000X
Hematology (Internal Medicine) Physician
MT183411
PA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1386804409
—
NC
05
—
NC1838
—
SC
Enumeration date
06/12/2008
Last updated
11/18/2020
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