Provider Demographics
NPI:1487335824
Name:ADEBAYO, ABIMBOLA CHARLES
Entity type:Individual
Prefix:
First Name:ABIMBOLA
Middle Name:CHARLES
Last Name:ADEBAYO
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 1:5457 TWIN KNOLLS RD STE 300-1116
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21045-3259
Mailing Address - Country:US
Mailing Address - Phone:667-417-9408
Mailing Address - Fax:
Practice Address - Street 1:5457 TWIN KNOLLS RD STE 300-1116
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21045-3259
Practice Address - Country:US
Practice Address - Phone:667-417-9408
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-28
Last Update Date:2025-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR240424363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health