Healthcare Provider Details

I. General information

NPI: 1396391777
Provider Name (Legal Business Name): GLORIA OBIAJULU
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2019
Last Update Date: 08/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 PEGASUS WAY
HAVRE DE GRACE MD
21078-2031
US

IV. Provider business mailing address

60 PEGASUS WAY
HAVRE DE GRACE MD
21078-2031
US

V. Phone/Fax

Practice location:
  • Phone: 301-768-0030
  • Fax:
Mailing address:
  • Phone: 301-768-0030
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberR115811
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: