Provider Demographics
NPI:1720639693
Name:OLUSANYA, OLUMIDE EBENEZER
Entity Type:Individual
Prefix:
First Name:OLUMIDE
Middle Name:EBENEZER
Last Name:OLUSANYA
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 1:8616 ACCOKEEK ST
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20724-1986
Mailing Address - Country:US
Mailing Address - Phone:443-525-5611
Mailing Address - Fax:
Practice Address - Street 1:8616 ACCOKEEK ST
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20724-1986
Practice Address - Country:US
Practice Address - Phone:443-525-5611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-23
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide