Healthcare Provider Details

I. General information

NPI: 1821015264
Provider Name (Legal Business Name): BENJAMIN ADEWALE MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2006
Last Update Date: 01/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7011 CALAMO ST #105
SPRINGFIELD VA
22150
US

IV. Provider business mailing address

PO BOX 8057
ALEXANDRIA VA
22306-8057
US

V. Phone/Fax

Practice location:
  • Phone: 703-569-8028
  • Fax: 703-569-8085
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QV0200X
TaxonomyVA Clinic/Center
License Number0101054165
License Number StateVA
# 4
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: BENJAMIN ADYSON ADENWALE
Title or Position: MEDICAL DIRECTOR MD
Credential: MD
Phone: 703-569-8028