Healthcare Provider Details

I. General information

NPI: 1679594030
Provider Name (Legal Business Name): OLUMUYIWA AKINNIYI OJEDIRAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

734 SOUTH SYCAMORE STREET
PETERSBURG VA
23803
US

IV. Provider business mailing address

734 S SYCAMORE STREET
PETERSBURG VA
23803
US

V. Phone/Fax

Practice location:
  • Phone: 804-733-0111
  • Fax: 804-733-1176
Mailing address:
  • Phone: 804-733-0111
  • Fax: 804-733-1176

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0101233648
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: