Provider Demographics
NPI:1417036880
Name:OKUSAMI, TAIWO (MD)
Entity Type:Individual
Prefix:DR
First Name:TAIWO
Middle Name:
Last Name:OKUSAMI
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 1:9 BITTERROOT CT
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20853-1770
Mailing Address - Country:US
Mailing Address - Phone:301-367-1080
Mailing Address - Fax:
Practice Address - Street 1:5280 LYNGATE CT
Practice Address - Street 2:
Practice Address - City:BURKE
Practice Address - State:VA
Practice Address - Zip Code:22015-1688
Practice Address - Country:US
Practice Address - Phone:703-217-2487
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101051317174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
437733Medicare ID - Type Unspecified