Provider Demographics
NPI:1417597295
Name:GARUBA, IDRIS OZEMOYA (MBA)
Entity type:Individual
Prefix:
First Name:IDRIS
Middle Name:OZEMOYA
Last Name:GARUBA
Suffix:
Gender:M
Credentials:MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6213 64TH AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:MD
Mailing Address - Zip Code:20737-2944
Mailing Address - Country:US
Mailing Address - Phone:301-437-0845
Mailing Address - Fax:
Practice Address - Street 1:6213 64TH AVE APT 1
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:MD
Practice Address - Zip Code:20737-2944
Practice Address - Country:US
Practice Address - Phone:301-437-0845
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-09
Last Update Date:2020-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA00186096253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care