Provider Demographics
NPI:1801677570
Name:BANKOLE, OLUBUKOLA SEGUN
Entity type:Individual
Prefix:
First Name:OLUBUKOLA
Middle Name:SEGUN
Last Name:BANKOLE
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 1:24 GWYNNSWOOD RD
Mailing Address - Street 2:
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117-1767
Mailing Address - Country:US
Mailing Address - Phone:240-938-4107
Mailing Address - Fax:
Practice Address - Street 1:24 GWYNNSWOOD RD
Practice Address - Street 2:
Practice Address - City:OWINGS MILLS
Practice Address - State:MD
Practice Address - Zip Code:21117-1767
Practice Address - Country:US
Practice Address - Phone:240-938-4107
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-10
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDRSA-02078374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Multi-Specialty