Healthcare Provider Details

I. General information

NPI: 1659552156
Provider Name (Legal Business Name): OLUMUYIWA OJEDIRAN, M.D P.C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/26/2007
Last Update Date: 11/26/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

734 S SYCAMORE ST
PETERSBURG VA
23803-5817
US

IV. Provider business mailing address

734 S SYCAMORE ST
PETERSBURG VA
23803-5817
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 Code207RA0000X
TaxonomyAdolescent Medicine (Internal Medicine) Physician
License Number0101233648
License Number StateVA

VIII. Authorized Official

Name: DR. OLUMUYIWA AKINNIYI OJEDIRAN
Title or Position: PRESIDENT
Credential: M.D
Phone: 804-733-0111