Healthcare Provider Details

I. General information

NPI: 1174926679
Provider Name (Legal Business Name): OLUFUNMILOLA MODUPE OGBONLOWO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2014
Last Update Date: 10/31/2025
Certification Date: 10/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19440 GOLF VISTA PLZ STE 120
LANSDOWNE VA
20176-8264
US

IV. Provider business mailing address

19440 GOLF VISTA PLZ STE 120
LANSDOWNE VA
20176-8264
US

V. Phone/Fax

Practice location:
  • Phone: 571-293-2424
  • Fax: 833-913-2348
Mailing address:
  • Phone: 571-293-2424
  • Fax: 833-913-2348

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301107153
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101263837
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License Number10421511
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: