Provider Demographics
NPI:1801365689
Name:OMOGOKE, OLUKEMI ROSELINE (MD)
Entity Type:Individual
Prefix:
First Name:OLUKEMI
Middle Name:ROSELINE
Last Name:OMOGOKE
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 1:12804 GREENES PROMISE CT
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20720-5613
Mailing Address - Country:US
Mailing Address - Phone:301-346-2201
Mailing Address - Fax:
Practice Address - Street 1:650 RITCHIE HWY STE 207
Practice Address - Street 2:
Practice Address - City:SEVERNA PARK
Practice Address - State:MD
Practice Address - Zip Code:21146-3935
Practice Address - Country:US
Practice Address - Phone:410-315-9350
Practice Address - Fax:410-421-9135
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-21
Last Update Date:2021-03-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MDR207593363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty