Provider Demographics
NPI:1871553594
Name:OMOHUNDRO, PHILLIP H (MD)
Entity type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:H
Last Name:OMOHUNDRO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:12200 ANNAPOLIS RD STE 123
Mailing Address - Street 2:
Mailing Address - City:GLENN DALE
Mailing Address - State:MD
Mailing Address - Zip Code:20769-9182
Mailing Address - Country:US
Mailing Address - Phone:301-364-9292
Mailing Address - Fax:855-291-3304
Practice Address - Street 1:12200 ANNAPOLIS RD STE 123
Practice Address - Street 2:
Practice Address - City:GLENN DALE
Practice Address - State:MD
Practice Address - Zip Code:20769-9182
Practice Address - Country:US
Practice Address - Phone:301-364-9292
Practice Address - Fax:855-291-3304
Is Sole Proprietor?:No
Enumeration Date:2006-03-25
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD13399207XX0005X, 207X00000X
MDD25458207X00000X, 207X00000X
MDD0025458207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD0150330001Medicaid
A82859Medicare UPIN
MDA82859Medicare UPIN
MDG01577Medicare PIN