Provider Demographics
NPI:1275397556
Name:OMADEVUAE, EFETOBORE
Entity Type:Individual
Prefix:MR
First Name:EFETOBORE
Middle Name:
Last Name:OMADEVUAE
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 1:6628 RIDGEBORNE DR
Mailing Address - Street 2:
Mailing Address - City:ROSEDALE
Mailing Address - State:MD
Mailing Address - Zip Code:21237-3871
Mailing Address - Country:US
Mailing Address - Phone:443-739-1209
Mailing Address - Fax:
Practice Address - Street 1:9 PINEKNOT CT
Practice Address - Street 2:
Practice Address - City:GWYNN OAK
Practice Address - State:MD
Practice Address - Zip Code:21207-5585
Practice Address - Country:US
Practice Address - Phone:443-739-1209
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-07
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness