Provider Demographics
NPI:1679522023
Name:JAGUN, OLABISI A (MD)
Entity Type:Individual
Prefix:DR
First Name:OLABISI
Middle Name:A
Last Name:JAGUN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12600 HILL CREEK LN
Mailing Address - Street 2:
Mailing Address - City:POTOMAC
Mailing Address - State:MD
Mailing Address - Zip Code:20854-1184
Mailing Address - Country:US
Mailing Address - Phone:240-401-5953
Mailing Address - Fax:
Practice Address - Street 1:12600 HILL CREEK LN
Practice Address - Street 2:
Practice Address - City:POTOMAC
Practice Address - State:MD
Practice Address - Zip Code:20854-1184
Practice Address - Country:US
Practice Address - Phone:240-401-5953
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-10
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD16916207P00000X
VA0101046802207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC030100500Medicaid
WV3810007727Medicaid
VA1679522023Medicaid
DCBJ3028784OtherDEA
DC030100500Medicaid
DCF05518Medicare UPIN
DCBJ3028784OtherDEA