Provider Demographics
NPI:1538425384
Name:ODUBENA, ISMAILA KOLAWOLE
Entity type:Individual
Prefix:
First Name:ISMAILA
Middle Name:KOLAWOLE
Last Name:ODUBENA
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 1:1705 SHAMROCK AVE
Mailing Address - Street 2:
Mailing Address - City:CAPITOL HEIGHTS
Mailing Address - State:MD
Mailing Address - Zip Code:20743-5302
Mailing Address - Country:US
Mailing Address - Phone:240-606-4620
Mailing Address - Fax:
Practice Address - Street 1:4651 PEBBLESHIRE CT
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20602-4108
Practice Address - Country:US
Practice Address - Phone:240-606-4620
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-05
Last Update Date:2018-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC174400000X
374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No174400000XOther Service ProvidersSpecialist