Healthcare Provider Details

I. General information

NPI: 1669969382
Provider Name (Legal Business Name): BAMIDELE OLAWALE JOHNSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: BAMIDELE OLAWALE JOHNSON MD

II. Dates (important events)

Enumeration Date: 04/18/2018
Last Update Date: 03/23/2026
Certification Date: 03/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 BROOKDALE PLZ
BROOKLYN NY
11212-3139
US

IV. Provider business mailing address

15005 HEALTH CENTER DR
BOWIE MD
20716-1017
US

V. Phone/Fax

Practice location:
  • Phone: 718-613-4334
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberD0104395
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: