Provider Demographics
NPI:1184184608
Name:OWOTOMO, OLUSEGUN OBAFEMI (MD)
Entity Type:Individual
Prefix:
First Name:OLUSEGUN
Middle Name:OBAFEMI
Last Name:OWOTOMO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 N WOLFE ST STE 3075
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21287-0011
Mailing Address - Country:US
Mailing Address - Phone:410-955-2035
Mailing Address - Fax:410-955-1030
Practice Address - Street 1:200 N WOLFE ST STE 3075
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21287-0011
Practice Address - Country:US
Practice Address - Phone:410-955-2035
Practice Address - Fax:410-955-1030
Is Sole Proprietor?:No
Enumeration Date:2019-03-21
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0093346208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics