Basic Information
| Provider Information | |||||||||
| NPI: | 1609187848 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ELEMIDE | ||||||||
| FirstName: | OLATOKUNBO | ||||||||
| MiddleName: | O | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 37174 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212973174 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5714235699 | ||||||||
| FaxNumber: | 5714235698 | ||||||||
| Practice Location | |||||||||
| Address1: | 2501 PARKERS LN | ||||||||
| Address2: | |||||||||
| City: | ALEXANDRIA | ||||||||
| State: | VA | ||||||||
| PostalCode: | 223063209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7036647000 | ||||||||
| FaxNumber: | 7036647666 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2010 | ||||||||
| LastUpdateDate: | 08/27/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | DC | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207R00000X | 0101254766 | VA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1609187848 | 05 | VA | MEDICAID |