Healthcare Provider Details

I. General information

NPI: 1245988120
Provider Name (Legal Business Name): ALDOUS PETER JOSHUA BARORO ODULIO PT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/10/2022
Last Update Date: 03/10/2022
Certification Date: 03/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12185 CLIPPER DR
LAKE RIDGE VA
22192-2236
US

IV. Provider business mailing address

3682 CHIPPENDALE CIR
WOODBRIDGE VA
22193-5355
US

V. Phone/Fax

Practice location:
  • Phone: 703-496-3400
  • Fax:
Mailing address:
  • Phone: 347-410-0253
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number010839
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2305214744
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number039677
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: