Provider Demographics
NPI:1730105297
Name:PAUL, OLUMUYIWA A (MD)
Entity Type:Individual
Prefix:DR
First Name:OLUMUYIWA
Middle Name:A
Last Name:PAUL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12150 ANNAPLOS ROAD
Mailing Address - Street 2:SUITE 305
Mailing Address - City:GLENN DALE
Mailing Address - State:MD
Mailing Address - Zip Code:20769
Mailing Address - Country:US
Mailing Address - Phone:240-245-4203
Mailing Address - Fax:240-245-4216
Practice Address - Street 1:12150 ANNAPOLIS ROAD
Practice Address - Street 2:SUITE 305
Practice Address - City:GLENN DALE
Practice Address - State:MD
Practice Address - Zip Code:20769
Practice Address - Country:US
Practice Address - Phone:240-245-4203
Practice Address - Fax:240-245-4216
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-15
Last Update Date:2011-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0052606174400000X
MD174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDG99489Medicare UPIN
MDG02058Medicare PIN