Healthcare Provider Details

I. General information

NPI: 1922035633
Provider Name (Legal Business Name): MARY OGUNSANYA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/27/2006
Last Update Date: 02/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12150 ANNAPOLIS RD SUITE 208
GLENN DALE MD
20769-9183
US

IV. Provider business mailing address

PO BOX 2132
BOWIE MD
20718-2132
US

V. Phone/Fax

Practice location:
  • Phone: 301-218-0398
  • Fax:
Mailing address:
  • Phone: 301-218-0398
  • Fax: 301-218-0040

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberD005630
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: