Provider Demographics
NPI:1821293036
Name:OGUNJUYIGBE, OLUMIDE (PT)
Entity Type:Individual
Prefix:
First Name:OLUMIDE
Middle Name:
Last Name:OGUNJUYIGBE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2909 EAGLES NEST DR
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20716-3905
Mailing Address - Country:US
Mailing Address - Phone:202-498-0484
Mailing Address - Fax:301-805-0634
Practice Address - Street 1:2909 EAGLES NEST DR
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20716-3905
Practice Address - Country:US
Practice Address - Phone:202-498-0484
Practice Address - Fax:301-805-0634
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD18415225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC5556Medicaid
DC5556Medicaid