Provider Demographics
NPI:1639687163
Name:OLASIMBO, OMOLARA
Entity Type:Individual
Prefix:
First Name:OMOLARA
Middle Name:
Last Name:OLASIMBO
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 1:1315 BRETON DR
Mailing Address - Street 2:
Mailing Address - City:ELDERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:21784-6137
Mailing Address - Country:US
Mailing Address - Phone:410-552-8289
Mailing Address - Fax:
Practice Address - Street 1:6701 N CHARLES ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21204-6808
Practice Address - Country:US
Practice Address - Phone:443-849-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-18
Last Update Date:2018-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0006739363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant