Provider Demographics
NPI:1528815776
Name:EJOLLE, PAUL BUSSE
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:BUSSE
Last Name:EJOLLE
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 1:12910 CLOVERLY DR
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20774-1902
Mailing Address - Country:US
Mailing Address - Phone:948-202-1340
Mailing Address - Fax:
Practice Address - Street 1:2501 MARION BARRY AVE SE # 1628
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20020-3011
Practice Address - Country:US
Practice Address - Phone:202-866-7505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-06
Last Update Date:2025-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD171M00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator