Provider Demographics
NPI:1902240930
Name:BALOGUN, KOFOWOROLA (MBI HEALTH SERVICES)
Entity Type:Individual
Prefix:
First Name:KOFOWOROLA
Middle Name:
Last Name:BALOGUN
Suffix:
Gender:F
Credentials:MBI HEALTH SERVICES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:309 EAGLES RIDGE WAY
Mailing Address - Street 2:
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21061-6754
Mailing Address - Country:US
Mailing Address - Phone:240-938-3395
Mailing Address - Fax:
Practice Address - Street 1:4130 HUNT PL NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20019-3565
Practice Address - Country:US
Practice Address - Phone:202-388-9202
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-21
Last Update Date:2023-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No251B00000XAgenciesCase Management