Healthcare Provider Details

I. General information

NPI: 1073429031
Provider Name (Legal Business Name): OLUWASEGUN JOHN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2026
Last Update Date: 08/20/2026
Certification Date: 08/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6308 DANNER DR
CLINTON MD
20735-3859
US

IV. Provider business mailing address

6308 DANNER DR
CLINTON MD
20735-3859
US

V. Phone/Fax

Practice location:
  • Phone: 301-364-8656
  • Fax:
Mailing address:
  • Phone: 301-364-8656
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name: OLUWASEGUN AJIBOLA JOHN
Title or Position: COMMUNITY SUPPORT WORKER
Credential:
Phone: 301-364-8656