Healthcare Provider Details

I. General information

NPI: 1902434152
Provider Name (Legal Business Name): OLOLADE SANUSI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2020
Last Update Date: 12/06/2023
Certification Date: 12/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6535 N CHARLES ST STE 100
BALTIMORE MD
21204-5828
US

IV. Provider business mailing address

6535 N CHARLES ST STE 100
BALTIMORE MD
21204-5828
US

V. Phone/Fax

Practice location:
  • Phone: 443-849-2707
  • Fax: 443-849-8066
Mailing address:
  • Phone: 443-849-2707
  • Fax: 443-849-8066

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberD0095577
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberD0096677
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: