Healthcare Provider Details

I. General information

NPI: 1710820113
Provider Name (Legal Business Name): MR. OLUWATOSIN PETER OMOLE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2026
Last Update Date: 04/10/2026
Certification Date: 04/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5625 HARVEY CT
WHITE MARSH MD
21162-1938
US

IV. Provider business mailing address

5625 HARVEY CT
WHITE MARSH MD
21162-1938
US

V. Phone/Fax

Practice location:
  • Phone: 443-801-1882
  • Fax:
Mailing address:
  • Phone: 443-801-1882
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberR197286
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: