MEDICARE: MR. JOHNSON O KOLAWOLE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	374U00000X	Home Health Aide	HHA200005883	DC
2	251E00000X	Home Health Agency
3	374U00000X	Home Health Aide		DC

General Provider Information

NPI Number	:	1649782764
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JOHNSON O KOLAWOLE

Provider Business Mailing Address
First Line	:	11486 SAMUEL BECKETT CT
Second Line	:
City	:	WHITE PLAINS
State	:	MD
Zip	:	20695-4254
Country	:	US
Telephone Number	:	240-646-2891
Fax Number	:

Provider Business Practice Location Address
First Line	:	4903 ASHFORD DR
Second Line	:
City	:	UPPR MARLBORO
State	:	MD
Zip	:	20772-2776
Country	:	US
Telephone Number	:	240-646-2891
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/30/2017
Last Update Date	:	04/16/2026

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