Healthcare Provider Details

I. General information

NPI: 1821293036
Provider Name (Legal Business Name): OLUMIDE OGUNJUYIGBE PT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2909 EAGLES NEST DR
BOWIE MD
20716-3905
US

IV. Provider business mailing address

2909 EAGLES NEST DR
BOWIE MD
20716-3905
US

V. Phone/Fax

Practice location:
  • Phone: 202-498-0484
  • Fax: 301-805-0634
Mailing address:
  • Phone: 202-498-0484
  • Fax: 301-805-0634

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberMD18415
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: