Healthcare Provider Details

I. General information

NPI: 1295005973
Provider Name (Legal Business Name): DR. SAMSON A OMOTOSHO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/11/2012
Last Update Date: 10/01/2025
Certification Date: 10/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 GARRISON BLVD SUITE 104
BALTIMORE MD
21216-2335
US

IV. Provider business mailing address

10701 CHAPELDALE RD
RANDALLSTOWN MD
21133-1044
US

V. Phone/Fax

Practice location:
  • Phone: 410-233-6200
  • Fax:
Mailing address:
  • Phone: 443-858-3189
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberR115849
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: