Provider Demographics
NPI:1689113516
Name:OGUNTOMI, OLUWASINA
Entity type:Individual
Prefix:
First Name:OLUWASINA
Middle Name:
Last Name:OGUNTOMI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7700 OLD BRANCH AVE STE C104
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MD
Mailing Address - Zip Code:20735-1628
Mailing Address - Country:US
Mailing Address - Phone:240-348-2444
Mailing Address - Fax:240-348-2454
Practice Address - Street 1:7700 OLD BRANCH AVE STE C104
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MD
Practice Address - Zip Code:20735-1628
Practice Address - Country:US
Practice Address - Phone:240-348-2444
Practice Address - Fax:240-348-2454
Is Sole Proprietor?:No
Enumeration Date:2017-02-12
Last Update Date:2024-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR217730363LP0808X
IL041429680163WP2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP2201XNursing Service ProvidersRegistered NurseAmbulatory Care
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health