Provider Demographics
NPI:1952818999
Name:OPTIMIZE MEDICAL GROUP
Entity Type:Organization
Organization Name:OPTIMIZE MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:KAMAU
Authorized Official - Last Name:NGUGI
Authorized Official - Suffix:
Authorized Official - Credentials:CRNP-C
Authorized Official - Phone:443-248-1929
Mailing Address - Street 1:PO BOX 72098
Mailing Address - Street 2:
Mailing Address - City:ROSEDALE
Mailing Address - State:MD
Mailing Address - Zip Code:21237-8098
Mailing Address - Country:US
Mailing Address - Phone:443-868-7101
Mailing Address - Fax:443-868-7956
Practice Address - Street 1:1314 BEDFORD AVE STE 113
Practice Address - Street 2:
Practice Address - City:PIKESVILLE
Practice Address - State:MD
Practice Address - Zip Code:21208-3737
Practice Address - Country:US
Practice Address - Phone:443-868-7101
Practice Address - Fax:443-868-7956
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-29
Last Update Date:2022-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR179125363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD444017000Medicaid