Healthcare Provider Details

I. General information

NPI: 1902755010
Provider Name (Legal Business Name): OLADAPO ODUSANYA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2026
Last Update Date: 08/14/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 EASTERN AVE STE B3
FAIRMOUNT HEIGHTS MD
20743-1677
US

IV. Provider business mailing address

5069 SILVER OAK DR
ROSEDALE MD
21237-3394
US

V. Phone/Fax

Practice location:
  • Phone: 571-418-4211
  • Fax:
Mailing address:
  • Phone: 908-875-3538
  • Fax: 908-875-3538

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberR238375
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: