Provider Demographics
NPI:1851981054
Name:COLE, OMOBOLA
Entity Type:Individual
Prefix:
First Name:OMOBOLA
Middle Name:
Last Name:COLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12509 WOODBRIDGE CT
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20721-4234
Mailing Address - Country:US
Mailing Address - Phone:301-633-7706
Mailing Address - Fax:
Practice Address - Street 1:12509 WOODBRIDGE CT
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20721-4234
Practice Address - Country:US
Practice Address - Phone:301-633-7706
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-21
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy