Healthcare Provider Details

I. General information

NPI: 1750397725
Provider Name (Legal Business Name): JENNIFER ODUTOLA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 12/05/2022
Certification Date: 12/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19500 SANDRIDGE WAY STE 170
LANSDOWNE VA
20176-3692
US

IV. Provider business mailing address

224D CORNWALL ST NW STE 403
LEESBURG VA
20176-2704
US

V. Phone/Fax

Practice location:
  • Phone: 703-723-3398
  • Fax: 703-723-7464
Mailing address:
  • Phone: 703-443-6717
  • Fax: 703-443-8643

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number0101234395
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: