Healthcare Provider Details

I. General information

NPI: 1538425384
Provider Name (Legal Business Name): ISMAILA KOLAWOLE ODUBENA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2012
Last Update Date: 09/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4651 PEBBLESHIRE CT
WALDORF MD
20602-4108
US

IV. Provider business mailing address

1705 SHAMROCK AVE
CAPITOL HEIGHTS MD
20743-5302
US

V. Phone/Fax

Practice location:
  • Phone: 240-606-4620
  • Fax:
Mailing address:
  • Phone: 240-606-4620
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: