Provider Demographics
NPI:1255014429
Name:ADEWUSI, OLUTOBA (MA)
Entity type:Individual
Prefix:
First Name:OLUTOBA
Middle Name:
Last Name:ADEWUSI
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 MILITARY PL APT 302
Mailing Address - Street 2:
Mailing Address - City:ODENTON
Mailing Address - State:MD
Mailing Address - Zip Code:21113-4608
Mailing Address - Country:US
Mailing Address - Phone:301-300-5839
Mailing Address - Fax:
Practice Address - Street 1:5621 OLD FREDERICK RD
Practice Address - Street 2:
Practice Address - City:CATONSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21228-1554
Practice Address - Country:US
Practice Address - Phone:301-300-5839
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-14
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDM06192225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist