Healthcare Provider Details

I. General information

NPI: 1164046587
Provider Name (Legal Business Name): OMOTOMILADE OLOPOENIA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2020
Last Update Date: 08/25/2024
Certification Date: 08/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 GALLOWS RD
FALLS CHURCH VA
22042-3300
US

IV. Provider business mailing address

2729 MERRILEE DR APT 203
FAIRFAX VA
22031-4431
US

V. Phone/Fax

Practice location:
  • Phone: 703-776-2745
  • Fax:
Mailing address:
  • Phone: 240-505-5121
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number0101281500
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: