Basic Information
| Provider Information | |||||||||
| NPI: | 1396418430 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | IBIDAPO | ||||||||
| FirstName: | AYODEJI | ||||||||
| MiddleName: | OLUMIDE | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | CRNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6518 RIDGEBORNE DR | ||||||||
| Address2: | |||||||||
| City: | ROSEDALE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212373803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3016935524 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2401 W BELVEDERE AVE | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212155216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4106019000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2021 | ||||||||
| LastUpdateDate: | 08/06/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | R182459 | MD | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
No ID Information.