Provider Demographics
NPI:1558706747
Name:OMOTOSHO, IDOWU EMMANUEL
Entity Type:Individual
Prefix:MR
First Name:IDOWU
Middle Name:EMMANUEL
Last Name:OMOTOSHO
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 1:4019 BRIDLE RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20772-8095
Mailing Address - Country:US
Mailing Address - Phone:240-535-2955
Mailing Address - Fax:
Practice Address - Street 1:9127 EDMONSTON TER
Practice Address - Street 2:#202
Practice Address - City:GREENBELT
Practice Address - State:MD
Practice Address - Zip Code:20770-1543
Practice Address - Country:US
Practice Address - Phone:240-535-2955
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-01
Last Update Date:2018-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCHHA8968374U00000X
374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide