Provider Demographics
NPI:1003848672
Name:JOHNSON, OMOLOLA O (MD)
Entity type:Individual
Prefix:
First Name:OMOLOLA
Middle Name:O
Last Name:JOHNSON
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 1:6020 HELEN DORSEY WAY
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21045-5046
Mailing Address - Country:US
Mailing Address - Phone:410-964-5711
Mailing Address - Fax:410-964-5711
Practice Address - Street 1:809 N HAMMONDS FERRY RD
Practice Address - Street 2:SUITE C
Practice Address - City:LINTHICUM
Practice Address - State:MD
Practice Address - Zip Code:21090-1317
Practice Address - Country:US
Practice Address - Phone:410-789-2500
Practice Address - Fax:410-789-2501
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2008-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD61341207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
I49822Medicare UPIN
MD533P061HMedicare PIN