Healthcare Provider Details

I. General information

NPI: 1164148367
Provider Name (Legal Business Name): ISRAEL OGUNSOLA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2022
Last Update Date: 05/20/2025
Certification Date: 05/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5136 BELAIR RD
BALTIMORE MD
21206-5146
US

IV. Provider business mailing address

5136 BELAIR RD
BALTIMORE MD
21206-5146
US

V. Phone/Fax

Practice location:
  • Phone: 240-373-7355
  • Fax: 808-515-5506
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number227669
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: