Healthcare Provider Details

I. General information

NPI: 1811411283
Provider Name (Legal Business Name): SAMUEL ONYEBUCHI IJOMA PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2017
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6948 MAYFAIR TER
LAUREL MD
20707-5213
US

IV. Provider business mailing address

PO BOX 7654
SILVER SPRING MD
20907-7654
US

V. Phone/Fax

Practice location:
  • Phone: 410-948-8906
  • Fax:
Mailing address:
  • Phone: 410-948-8906
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332BD1200X
TaxonomyDialysis Equipment & Supplies (DME)
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: