Provider Demographics
NPI:1770066623
Name:ODEBODE, OLAMIPO
Entity type:Individual
Prefix:
First Name:OLAMIPO
Middle Name:
Last Name:ODEBODE
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 1:6655 SANTA BARBARA RD
Mailing Address - Street 2:
Mailing Address - City:ELKRIDGE
Mailing Address - State:MD
Mailing Address - Zip Code:21075-7500
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6655 SANTA BARBARA RD
Practice Address - Street 2:
Practice Address - City:ELKRIDGE
Practice Address - State:MD
Practice Address - Zip Code:21075-7500
Practice Address - Country:US
Practice Address - Phone:866-968-6342
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-06
Last Update Date:2025-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR217298363LF0000X
COC-APN.0002302-C-NP363LP0808X
390200000X
MDAC006685363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program