Healthcare Provider Details

I. General information

NPI: 1871588079
Provider Name (Legal Business Name): MODUPE ODUNUGA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/13/2005
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6122 LANDOVER RD
CHEVERLY MD
20785-1016
US

IV. Provider business mailing address

18 NANTUCKET CT
POTOMAC MD
20854-4423
US

V. Phone/Fax

Practice location:
  • Phone: 301-322-2411
  • Fax: 301-322-2412
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberD45663
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License NumberD45663
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: