Healthcare Provider Details

I. General information

NPI: 1437466117
Provider Name (Legal Business Name): AJIBOLA OGUNNUSI O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2010
Last Update Date: 09/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 BOSTON ST
BALTIMORE MD
21224-4723
US

IV. Provider business mailing address

3726 PIKESWOOD DR
RANDALLSTOWN MD
21133-2718
US

V. Phone/Fax

Practice location:
  • Phone: 410-675-0434
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTA2202
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: