Healthcare Provider Details

I. General information

NPI: 1871689331
Provider Name (Legal Business Name): OLUMUYIWA GISANRIN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 03/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 MONTICELLO AVE
WILLIAMSBURG VA
23185-2840
US

IV. Provider business mailing address

PO BOX 5508
VIRGINIA BEACH VA
23471-0508
US

V. Phone/Fax

Practice location:
  • Phone: 757-564-3627
  • Fax: 757-564-6449
Mailing address:
  • Phone: 757-340-3489
  • Fax: 757-340-4278

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101238858
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: