Provider Demographics
NPI:1376037630
Name:OSUNTUYI, IFEDAYO
Entity type:Individual
Prefix:
First Name:IFEDAYO
Middle Name:
Last Name:OSUNTUYI
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 1:3808 ENDERS LN
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20716-7330
Mailing Address - Country:US
Mailing Address - Phone:301-351-0514
Mailing Address - Fax:
Practice Address - Street 1:2021 W PRATT ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21223-2242
Practice Address - Country:US
Practice Address - Phone:410-566-1360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-20
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD16305183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDO253331660817OtherDRIVERS LICENSE