Provider Demographics
NPI:1336707967
Name:OGUNDERO, OLUBUNMI M
Entity Type:Individual
Prefix:
First Name:OLUBUNMI
Middle Name:M
Last Name:OGUNDERO
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 1:5401 66TH PL
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:MD
Mailing Address - Zip Code:20737-3001
Mailing Address - Country:US
Mailing Address - Phone:240-505-9435
Mailing Address - Fax:
Practice Address - Street 1:5401 66TH PL
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:MD
Practice Address - Zip Code:20737-3001
Practice Address - Country:US
Practice Address - Phone:240-505-9435
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-29
Last Update Date:2019-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDC1442761254019909Medicaid