Healthcare Provider Details

I. General information

NPI: 1578906897
Provider Name (Legal Business Name): MR. BABATUNDE JIMOH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/17/2013
Last Update Date: 05/18/2026
Certification Date: 05/18/2026
Deactivation Date: 09/27/2024
Reactivation Date: 10/31/2024

III. Provider practice location address

6490 LANDOVER RD STE D3
CHEVERLY MD
20785-1443
US

IV. Provider business mailing address

6490 LANDOVER RD STE D3
CHEVERLY MD
20785-1443
US

V. Phone/Fax

Practice location:
  • Phone: 240-413-4131
  • Fax:
Mailing address:
  • Phone: 240-413-4131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: