Provider Demographics
NPI:1265205058
Name:BALOGUN, OLUSOLA
Entity type:Individual
Prefix:
First Name:OLUSOLA
Middle Name:
Last Name:BALOGUN
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 1:8312 SPADDERDOCK WAY
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20724-2943
Mailing Address - Country:US
Mailing Address - Phone:240-643-9459
Mailing Address - Fax:
Practice Address - Street 1:4017 MINNESOTA AVE NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20019-3541
Practice Address - Country:US
Practice Address - Phone:202-388-9200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-02
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator