Basic Information
| Provider Information | |||||||||
| NPI: | 1457346850 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OMOHUNDRO | ||||||||
| FirstName: | CRAIG | ||||||||
| MiddleName: | DEAN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4300 W MAIN ST | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | DOTHAN | ||||||||
| State: | AL | ||||||||
| PostalCode: | 363051054 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3347939564 | ||||||||
| FaxNumber: | 3346718907 | ||||||||
| Practice Location | |||||||||
| Address1: | 4300 W MAIN ST | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | DOTHAN | ||||||||
| State: | AL | ||||||||
| PostalCode: | 363051054 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3347939564 | ||||||||
| FaxNumber: | 3346718907 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2005 | ||||||||
| LastUpdateDate: | 10/22/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | 20605 | AL | Y | Allopathic & Osteopathic Physicians | Dermatology | 207ND0101X | 20605 | AL | N | Allopathic & Osteopathic Physicians | Dermatology | MOHS-Micrographic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 255070900 | 05 | FL | MEDICAID | 00749185A | 05 | GA | MEDICAID | 000032376 | 05 | AL | MEDICAID |