Healthcare Provider Details

I. General information

NPI: 1669388732
Provider Name (Legal Business Name): MED36-5
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2026
Last Update Date: 08/20/2026
Certification Date: 08/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3261 OLD WASHINGTON RD
WALDORF MD
20602-3223
US

IV. Provider business mailing address

3261 OLD WASHINGTON RD
WALDORF MD
20602-3223
US

V. Phone/Fax

Practice location:
  • Phone: 445-249-7879
  • Fax:
Mailing address:
  • Phone: 445-249-7879
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: DR. KEHINDE TOM AYEGUNLE
Title or Position: CEO
Credential: MD, MPH, CPRP
Phone: 445-249-7879