Provider Demographics
NPI:1649782764
Name:KOLAWOLE, JOHNSON O
Entity type:Individual
Prefix:MR
First Name:JOHNSON
Middle Name:O
Last Name:KOLAWOLE
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 1:4903 ASHFORD DR
Mailing Address - Street 2:
Mailing Address - City:UPPR MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20772-2776
Mailing Address - Country:US
Mailing Address - Phone:240-646-2891
Mailing Address - Fax:
Practice Address - Street 1:4903 ASHFORD DR
Practice Address - Street 2:
Practice Address - City:UPPR MARLBORO
Practice Address - State:MD
Practice Address - Zip Code:20772-2776
Practice Address - Country:US
Practice Address - Phone:240-646-2891
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-30
Last Update Date:2017-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide