Healthcare Provider Details

I. General information

NPI: 1194010678
Provider Name (Legal Business Name): OLUFEMI EBUNOLU BALOGUN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2011
Last Update Date: 06/10/2021
Certification Date: 06/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1221 MERCANTILE LN
UPPER MARLBORO MD
20774-5374
US

IV. Provider business mailing address

2101 E JEFFERSON ST STE 6W
ROCKVILLE MD
20852-4908
US

V. Phone/Fax

Practice location:
  • Phone: 301-618-5500
  • Fax:
Mailing address:
  • Phone: 301-816-5853
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD044945
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101262023
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberD83130
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: