MEDICARE: ODILIA BONGSE JATOR NP

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	363LF0000X	Family Nurse Practitioner	R196552	MD

General Provider Information

NPI Number	:	1922962885
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ODILIA BONGSE JATOR NP

Provider Business Mailing Address
First Line	:	1220B E JOPPA RD STE 324
Second Line	:
City	:	TOWSON
State	:	MD
Zip	:	21286-5823
Country	:	US
Telephone Number	:	410-494-1888
Fax Number	:	410-494-1008

Provider Business Practice Location Address
First Line	:	1220B E JOPPA RD STE 324
Second Line	:
City	:	TOWSON
State	:	MD
Zip	:	21286-5823
Country	:	US
Telephone Number	:	410-494-1888
Fax Number	:

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

Provider Enumeration Date	:	12/15/2025
Last Update Date	:	02/16/2026

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