Provider Demographics
NPI:1336450220
Name:OTUBANJO, OLUFEMI (PA-C)
Entity type:Individual
Prefix:
First Name:OLUFEMI
Middle Name:
Last Name:OTUBANJO
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6480 OLD WATERLOO RD
Mailing Address - Street 2:
Mailing Address - City:ELKRIDGE
Mailing Address - State:MD
Mailing Address - Zip Code:21075-6508
Mailing Address - Country:US
Mailing Address - Phone:202-340-4399
Mailing Address - Fax:
Practice Address - Street 1:6480 OLD WATERLOO RD
Practice Address - Street 2:
Practice Address - City:ELKRIDGE
Practice Address - State:MD
Practice Address - Zip Code:21075-6508
Practice Address - Country:US
Practice Address - Phone:410-799-0291
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-25
Last Update Date:2020-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0004195363AM0700X
MDC004195363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical