Healthcare Provider Details

I. General information

NPI: 1275820664
Provider Name (Legal Business Name): OLADUNNI MODINAT ENILARI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2011
Last Update Date: 08/26/2020
Certification Date: 08/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12200 WARWICK BLVD STE 290
NEWPORT NEWS VA
23601-2344
US

IV. Provider business mailing address

856 J CLYDE MORRIS BLVD STE A
NEWPORT NEWS VA
23601-1318
US

V. Phone/Fax

Practice location:
  • Phone: 757-534-5454
  • Fax: 757-534-5491
Mailing address:
  • Phone: 757-316-5800
  • Fax: 757-534-5190

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number0101266889
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number2014-01432
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: