Provider Demographics
NPI:1295005973
Name:OMOTOSHO, SAMSON A
Entity Type:Individual
Prefix:DR
First Name:SAMSON
Middle Name:A
Last Name:OMOTOSHO
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 1:10701 CHAPELDALE RD
Mailing Address - Street 2:
Mailing Address - City:RANDALLSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21133-1044
Mailing Address - Country:US
Mailing Address - Phone:443-858-3189
Mailing Address - Fax:
Practice Address - Street 1:2300 GARRISON BLVD
Practice Address - Street 2:SUITE 104
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21216-2335
Practice Address - Country:US
Practice Address - Phone:410-233-6200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-11
Last Update Date:2012-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR115849163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health