Healthcare Provider Details

I. General information

NPI: 1053078253
Provider Name (Legal Business Name): OKECHUKWU MATTHEW OFODILE CRNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2021
Last Update Date: 06/24/2025
Certification Date: 06/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 HARRY S TRUMAN DR N
LARGO MD
20774-5477
US

IV. Provider business mailing address

901 HARRY S TRUMAN DR N
LARGO MD
20774-5477
US

V. Phone/Fax

Practice location:
  • Phone: 240-677-2700
  • Fax:
Mailing address:
  • Phone: 240-677-2700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95031720
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberR215860
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberR215860
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: