Provider Demographics
NPI:1497272777
Name:OLAWALE, OLUFEMI (NP)
Entity Type:Individual
Prefix:
First Name:OLUFEMI
Middle Name:
Last Name:OLAWALE
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3507 N ROLLING RD
Mailing Address - Street 2:
Mailing Address - City:WINDSOR MILL
Mailing Address - State:MD
Mailing Address - Zip Code:21244-2203
Mailing Address - Country:US
Mailing Address - Phone:442-272-2614
Mailing Address - Fax:443-272-2664
Practice Address - Street 1:2500 N ROLLING RD
Practice Address - Street 2:STE 100
Practice Address - City:WINDSOR MILL
Practice Address - State:MD
Practice Address - Zip Code:21244-1999
Practice Address - Country:US
Practice Address - Phone:443-272-2614
Practice Address - Fax:443-272-2664
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-27
Last Update Date:2020-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR182894363L00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD500166800Medicaid