Basic Information
| Provider Information | |||||||||
| NPI: | 1962663328 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OWOLABI | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | TEMITOPE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13403 VOLVO WAY | ||||||||
| Address2: | MEDICAL SUITE | ||||||||
| City: | HAGERSTOWN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217423810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2405003764 | ||||||||
| FaxNumber: | 3017902050 | ||||||||
| Practice Location | |||||||||
| Address1: | 46 WALNUT BOTTOM RD | ||||||||
| Address2: | |||||||||
| City: | SHIPPENSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 172578219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7175324148 | ||||||||
| FaxNumber: | 7175323561 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2008 | ||||||||
| LastUpdateDate: | 01/19/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 37404 | AZ | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | MD436726 | PA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 283716 | 01 | PA | UNISON | OTHER | MD436726 | 01 | PA | LICENSE | OTHER | 1007307260034 | 01 | PA | MEDICAID GROUP # | OTHER | 102330222 0001 | 05 | PA | MEDICAID | 120420408 | 01 | PA | DEPT OF LABOR | OTHER | 25-1716306 | 01 | PA | DEVON | OTHER | 25-1716306 | 01 | PA | MULTIPLAN/PHCS | OTHER | 251716306 | 01 | PA | MAMSI | OTHER | 251716306 | 01 | PA | SOUTH CENTRAL PREFERRED | OTHER | 2218823 | 01 | PA | MAMSI | OTHER | 251716306 | 01 | PA | INFORMED | OTHER | 6950335 | 01 | PA | AETNA HMO | OTHER | 867633 | 01 | PA | MEDICARE GROUP # | OTHER | 1962663328 | 01 | PA | HEALTH AMERICA | OTHER | 251716306 | 01 | PA | DEVON HEALTH | OTHER | U947-0001 | 01 | PA | CAREFIRST DC | OTHER | 251716306 | 01 | PA | HEALTHNET/TRICARE | OTHER | 25-1716306 | 01 | PA | INTERGROUP | OTHER | 50086441 | 01 | PA | CAPITAL BLUECROSS | OTHER | 955397-01 | 01 | PA | CAREFIRST MD | OTHER | P00746970 | 01 | PA | RAILROAD MEDICARE | OTHER | 25-1716306 | 01 | PA | GREATWEST HEALTHCARE | OTHER | 434942 | 01 | PA | HIGHMARK BLUE SHIELD GROUP # | OTHER | 9474363 | 01 | PA | AETNA NON-HMO | OTHER | P0010038 | 01 | PA | GATEWAY | OTHER | 1962663328 | 01 | PA | FIRST HEALTH | OTHER | FO0512714 | 01 | PA | DEA | OTHER | OW2128757 | 01 | PA | HIGHMARK BLUESHIELD | OTHER |