Provider Demographics
NPI:1518280874
Name:IBIDUN, OLUWAKEMI OMOTOLA (RPT)
Entity Type:Individual
Prefix:MS
First Name:OLUWAKEMI
Middle Name:OMOTOLA
Last Name:IBIDUN
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3506 ETON DR
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20772-6805
Mailing Address - Country:US
Mailing Address - Phone:301-780-3390
Mailing Address - Fax:
Practice Address - Street 1:3506 ETON DR
Practice Address - Street 2:
Practice Address - City:UPPER MARLBORO
Practice Address - State:MD
Practice Address - Zip Code:20772-6805
Practice Address - Country:US
Practice Address - Phone:301-780-3390
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-01
Last Update Date:2010-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD18263225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist