Provider Demographics
NPI:1831305671
Name:AJIBOLA, OMOTUNDE O
Entity type:Individual
Prefix:
First Name:OMOTUNDE
Middle Name:O
Last Name:AJIBOLA
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 1:9913 GREENBELT RD APT 202
Mailing Address - Street 2:
Mailing Address - City:LANHAM
Mailing Address - State:MD
Mailing Address - Zip Code:20706-2244
Mailing Address - Country:US
Mailing Address - Phone:240-838-0599
Mailing Address - Fax:
Practice Address - Street 1:2512 24TH ST NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20018-2126
Practice Address - Country:US
Practice Address - Phone:202-832-8340
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
374U00000X
DC171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No374U00000XNursing Service Related ProvidersHome Health Aide