Healthcare Provider Details

I. General information

NPI: 1689171217
Provider Name (Legal Business Name): OPETOMI OMORINSOLA SERIKI DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2018
Last Update Date: 05/17/2026
Certification Date: 05/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8109 TIS WELL DRIVE SUITE 511
ALEXANDRIA VA
22306
US

IV. Provider business mailing address

PO BOX 37189
BALTIMORE MD
21297-3189
US

V. Phone/Fax

Practice location:
  • Phone: 703-779-9500
  • Fax: 703-779-9502
Mailing address:
  • Phone: 571-423-5699
  • Fax: 571-423-5699

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0102207980
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: