Provider Demographics
NPI:1316541824
Name:ADEFIYIJU, MODUPE O
Entity Type:Individual
Prefix:
First Name:MODUPE
Middle Name:O
Last Name:ADEFIYIJU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14205 DOWNDALE CT
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20707-6883
Mailing Address - Country:US
Mailing Address - Phone:443-739-6121
Mailing Address - Fax:
Practice Address - Street 1:7055 SAMUEL MORSE DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21046-3439
Practice Address - Country:US
Practice Address - Phone:443-739-6121
Practice Address - Fax:301-725-0163
Is Sole Proprietor?:No
Enumeration Date:2020-11-24
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR183736363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily