Provider Demographics
NPI:1902268352
Name:OSASUYI, FAMOUS IWINOSA
Entity Type:Individual
Prefix:MR
First Name:FAMOUS
Middle Name:IWINOSA
Last Name:OSASUYI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11555 AUTUMN TERRACE DR
Mailing Address - Street 2:
Mailing Address - City:WHITE MARSH
Mailing Address - State:MD
Mailing Address - Zip Code:21162-1152
Mailing Address - Country:US
Mailing Address - Phone:443-226-6339
Mailing Address - Fax:443-919-0209
Practice Address - Street 1:11555 AUTUMN TERRACE DR
Practice Address - Street 2:
Practice Address - City:WHITE MARSH
Practice Address - State:MD
Practice Address - Zip Code:21162-1152
Practice Address - Country:US
Practice Address - Phone:443-226-6339
Practice Address - Fax:443-919-0209
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-24
Last Update Date:2016-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities