Healthcare Provider Details

I. General information

NPI: 1578945507
Provider Name (Legal Business Name): MARK OLUWATOBI OWOLABI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2015
Last Update Date: 04/18/2024
Certification Date: 04/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3946 MINNESOTA AVE NE
WASHINGTON DC
20019-2661
US

IV. Provider business mailing address

3946 MINNESOTA AVE NE
WASHINGTON DC
20019-2661
US

V. Phone/Fax

Practice location:
  • Phone: 202-469-4699
  • Fax:
Mailing address:
  • Phone: 202-469-4699
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301119422
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD190064
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberS0040
License Number StateTX
# 4
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD-20031
License Number StateHI
# 5
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2018-01234
License Number StateNC
# 6
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD210003103
License Number StateDC
# 7
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number85026
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: