MEDICARE: OPTIMAL SLEEP AND WEIGHT LOSS CLINIC, PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QS1200X	Sleep Disorder Diagnostic Clinic/Center
2	207RS0012X	Sleep Medicine (Internal Medicine) Physician

General Provider Information

NPI Number	:	1962103747
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OPTIMAL SLEEP AND WEIGHT LOSS CLINIC, PLLC

Provider Business Mailing Address
First Line	:	13 CARROLL DR
Second Line	:
City	:	STAFFORD
State	:	VA
Zip	:	22554-5340
Country	:	US
Telephone Number	:	703-955-5355
Fax Number	:

Provider Business Practice Location Address
First Line	:	13000 HARBOR CENTER DR STE 212
Second Line	:
City	:	WOODBRIDGE
State	:	VA
Zip	:	22192-2847
Country	:	US
Telephone Number	:	703-955-5355
Fax Number	:	703-955-5348

Authorized Official
Title or Position	:	MANAGER
Name	:	PASCAL NGONGMON
Credential	:	MD
Telephone Number	:	703-955-5355

Provider Enumeration Date	:	03/17/2023
Last Update Date	:	12/22/2025

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