Provider Demographics
NPI:1164060943
Name:IGE, PETER OLUSOLA
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:OLUSOLA
Last Name:IGE
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 1:12 ROZINA CT
Mailing Address - Street 2:
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117-1318
Mailing Address - Country:US
Mailing Address - Phone:410-446-1294
Mailing Address - Fax:
Practice Address - Street 1:5411 OLD FREDERICK RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21229-2195
Practice Address - Country:US
Practice Address - Phone:410-762-8945
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-12
Last Update Date:2019-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR142898363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health