Healthcare Provider Details

I. General information

NPI: 1740430305
Provider Name (Legal Business Name): IBUKUN-OLU AKINYEMI ISAACS M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: IBUKUN OLU AKINYEMI ISAACS M.D.,

II. Dates (important events)

Enumeration Date: 09/19/2008
Last Update Date: 02/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23507 HOLLYWOOD RD STE 2
LEONARDTOWN MD
20650-5833
US

IV. Provider business mailing address

23507 HOLLYWOOD RD STE 2
LEONARDTOWN MD
20650-5833
US

V. Phone/Fax

Practice location:
  • Phone: 301-475-8860
  • Fax: 301-473-3843
Mailing address:
  • Phone: 301-475-8860
  • Fax: 301-473-3843

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberD0071845
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberFI1257763
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: