Provider Demographics
NPI:1992978910
Name:OSARENKHOE, ILEVBA UWAILA (MD)
Entity type:Individual
Prefix:
First Name:ILEVBA
Middle Name:UWAILA
Last Name:OSARENKHOE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7503 SURRATTS RD
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MD
Mailing Address - Zip Code:20735-3358
Mailing Address - Country:US
Mailing Address - Phone:301-868-8000
Mailing Address - Fax:
Practice Address - Street 1:7503 SURRATTS RD
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MD
Practice Address - Zip Code:20735-3358
Practice Address - Country:US
Practice Address - Phone:301-868-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-10
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA255678208000000X
MDD0067100208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110097583AMedicaid
MA003439901Medicare PIN