Basic Information
| Provider Information | |||||||||
| NPI: | 1093960130 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PICKERING | ||||||||
| FirstName: | OLUFUNKE | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. MBA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | OLUMEGBON | ||||||||
| OtherFirstName: | OLUFUNKE | ||||||||
| OtherMiddleName: | S | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1111 N CHARLES ST | ||||||||
| Address2: | 112 | ||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212017428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4108372050 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 111 N CHARLES ST | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212013803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4108372050 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2008 | ||||||||
| LastUpdateDate: | 02/08/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 60251065 | NY | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 046982 | CT | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | D0068784 | MD | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.