Healthcare Provider Details

I. General information

NPI: 1447831425
Provider Name (Legal Business Name): MOJISOLA OGUNBODE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2021
Last Update Date: 04/20/2021
Certification Date: 03/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9407 PLANETREE CIR
OWINGS MILLS MD
21117
US

IV. Provider business mailing address

10821 RED RUN BLVD UNIT 8
OWINGS MILLS MD
21117-8513
US

V. Phone/Fax

Practice location:
  • Phone: 443-212-8121
  • Fax: 443-356-6317
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: