Provider Demographics
NPI:1609617430
Name:LAWAL, IBUKUN
Entity type:Individual
Prefix:
First Name:IBUKUN
Middle Name:
Last Name:LAWAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20500 SENECA MEADOWS PKWY STE 101
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:20876-7009
Mailing Address - Country:US
Mailing Address - Phone:240-771-4983
Mailing Address - Fax:
Practice Address - Street 1:20500 SENECA MEADOWS PKWY
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:MD
Practice Address - Zip Code:20876-7008
Practice Address - Country:US
Practice Address - Phone:240-771-4983
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-05
Last Update Date:2024-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD30221225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist