Healthcare Provider Details

I. General information

NPI: 1578985354
Provider Name (Legal Business Name): AYODEJI OGUNIBE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2014
Last Update Date: 01/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4802 STOCKTON LN
LANDOVER HILLS MD
20784-1447
US

IV. Provider business mailing address

4802 STOCKTON LN
LANDOVER HILLS MD
20784-1447
US

V. Phone/Fax

Practice location:
  • Phone: 240-899-2322
  • Fax: 301-306-5334
Mailing address:
  • Phone: 240-899-2322
  • Fax: 301-306-5334

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License NumberW14852420
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: