Provider Demographics
NPI:1861266835
Name:OBIOGBOLU, AFOMA P
Entity type:Individual
Prefix:
First Name:AFOMA
Middle Name:P
Last Name:OBIOGBOLU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6800 MCCORMICK RD
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20772-4351
Mailing Address - Country:US
Mailing Address - Phone:240-899-5314
Mailing Address - Fax:
Practice Address - Street 1:10511 CAMPUS WAY S
Practice Address - Street 2:
Practice Address - City:UPPER MARLBORO
Practice Address - State:MD
Practice Address - Zip Code:20774-1308
Practice Address - Country:US
Practice Address - Phone:240-899-5314
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-10
Last Update Date:2023-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR239206163W00000X, 163WP0808X
DCRN1054227163WP0808X, 163W00000X
MD030175207U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
No207U00000XAllopathic & Osteopathic PhysiciansNuclear Medicine