Provider Demographics
NPI:1497522759
Name:SOYOMBO, OLUSEGUN
Entity Type:Individual
Prefix:
First Name:OLUSEGUN
Middle Name:
Last Name:SOYOMBO
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 1:400 SYMPHONY CIR UNIT 354
Mailing Address - Street 2:
Mailing Address - City:HUNT VALLEY
Mailing Address - State:MD
Mailing Address - Zip Code:21030-2039
Mailing Address - Country:US
Mailing Address - Phone:443-355-3785
Mailing Address - Fax:
Practice Address - Street 1:400 SYMPHONY CIR UNIT 354
Practice Address - Street 2:
Practice Address - City:HUNT VALLEY
Practice Address - State:MD
Practice Address - Zip Code:21030-2039
Practice Address - Country:US
Practice Address - Phone:443-355-3785
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-07
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator