Provider Demographics
NPI:1790029502
Name:KOMOLAFE, ABASS BALOGUN
Entity Type:Individual
Prefix:
First Name:ABASS
Middle Name:BALOGUN
Last Name:KOMOLAFE
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 1:11218 EVANS TRL APT T3
Mailing Address - Street 2:
Mailing Address - City:BELTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20705-3912
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2312 RHODE ISLANDE AVE NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20018
Practice Address - Country:US
Practice Address - Phone:202-635-6006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-16
Last Update Date:2012-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide