Provider Demographics
NPI:1851935183
Name:OMOBO, BAMIDELE
Entity Type:Individual
Prefix:
First Name:BAMIDELE
Middle Name:
Last Name:OMOBO
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 1:17008 USHER PL
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20772-3443
Mailing Address - Country:US
Mailing Address - Phone:240-552-2638
Mailing Address - Fax:
Practice Address - Street 1:17008 USHER PL
Practice Address - Street 2:
Practice Address - City:UPPER MARLBORO
Practice Address - State:MD
Practice Address - Zip Code:20772-3443
Practice Address - Country:US
Practice Address - Phone:240-552-2638
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-30
Last Update Date:2019-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide