Provider Demographics
NPI:1467890855
Name:OLOTU, ADEOLA
Entity Type:Individual
Prefix:
First Name:ADEOLA
Middle Name:
Last Name:OLOTU
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 1:1232 RACE ROAD
Mailing Address - Street 2:STE 403
Mailing Address - City:ROSEDALE
Mailing Address - State:MD
Mailing Address - Zip Code:21237
Mailing Address - Country:US
Mailing Address - Phone:443-868-7101
Mailing Address - Fax:443-732-0054
Practice Address - Street 1:1232 RACE ROAD
Practice Address - Street 2:STE 403
Practice Address - City:ROSEDALE
Practice Address - State:MD
Practice Address - Zip Code:21237
Practice Address - Country:US
Practice Address - Phone:443-868-7101
Practice Address - Fax:443-732-0054
Is Sole Proprietor?:No
Enumeration Date:2013-06-07
Last Update Date:2022-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR174288363LA2200X, 363LG0600X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD417106300Medicaid