Healthcare Provider Details

I. General information

NPI: 1043438716
Provider Name (Legal Business Name): MICHAEL OGBOLU
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 LIBERTY HEIGHTS AVE
BALTIMORE MD
21215-7804
US

IV. Provider business mailing address

2600 LIBERTY HEIGHTS AVE
BALTIMORE MD
21215-7804
US

V. Phone/Fax

Practice location:
  • Phone: 410-383-4615
  • Fax: 410-383-4606
Mailing address:
  • Phone: 410-383-4615
  • Fax: 410-383-4606

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247ZC0005X
TaxonomyClinical Laboratory Director (Non-physician)
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: