Healthcare Provider Details

I. General information

NPI: 1053775148
Provider Name (Legal Business Name): TEMITAYO AKINSODE OGUNDIPE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2016
Last Update Date: 11/11/2022
Certification Date: 11/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 GALLOWS RD
FALLS CHURCH VA
22042-3307
US

IV. Provider business mailing address

100 SENTARA CIR RM 2C
WILLIAMSBURG VA
23188-5713
US

V. Phone/Fax

Practice location:
  • Phone: 703-776-4001
  • Fax: 703-776-7113
Mailing address:
  • Phone: 757-984-7217
  • Fax: 757-984-7210

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number0101269988
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0101269988
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: