Provider Demographics
NPI:1033511753
Name:OGUNJEMILUA, SAMSON O
Entity type:Individual
Prefix:
First Name:SAMSON
Middle Name:O
Last Name:OGUNJEMILUA
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 1:14950 NASHUA LN
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20716-1006
Mailing Address - Country:US
Mailing Address - Phone:240-938-0748
Mailing Address - Fax:
Practice Address - Street 1:14950 NASHUA LN
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20716-1006
Practice Address - Country:US
Practice Address - Phone:240-938-0748
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-25
Last Update Date:2014-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCLPN 1007809164W00000X, 374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No164W00000XNursing Service ProvidersLicensed Practical Nurse