Individual
OMODELE JULIE MASHA
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
518 BROOKDALE DR, STATESVILLE, NC 28677-4108
(704) 872-9595
Mailing address
200 E 2ND AVE, GASTONIA, NC 28052-4358
(704) 874-0567
(704) 874-0707
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
2009-01717
NC
207R00000X
Internal Medicine Physician
2009-01717
NC
208000000X
Pediatrics Physician
Primary
2009-01717
NC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
09430542
—
MS
05
—
1051675
—
LA
05
—
1528164324
—
NC
01
—
154VV
BCNC
NC
05
—
NC1004
—
SC
Enumeration date
09/16/2006
Last updated
03/17/2018
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