Healthcare Provider Details

I. General information

NPI: 1689113516
Provider Name (Legal Business Name): OLUWASINA OGUNTOMI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2017
Last Update Date: 09/14/2026
Certification Date: 09/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8901 ROCKVILLE PIKE
BETHESDA MD
20889-0001
US

IV. Provider business mailing address

7700 OLD BRANCH AVE STE C104
CLINTON MD
20735-1628
US

V. Phone/Fax

Practice location:
  • Phone: 130-129-5400
  • Fax:
Mailing address:
  • Phone: 240-348-2444
  • Fax: 240-348-2454

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberR217730
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: