Healthcare Provider Details

I. General information

NPI: 1841358835
Provider Name (Legal Business Name): OLAKUNLE O ABISUGA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 02/04/2022
Certification Date: 02/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14139 POTOMAC MILLS ROAD
WOODBRIDGE VA
22192-4644
US

IV. Provider business mailing address

2101 E JEFFERSON ST KAISER PERMANENTE MEDICARE ENROLLMENT
ROCKVILLE MD
20852-4908
US

V. Phone/Fax

Practice location:
  • Phone: 703-490-8400
  • Fax: 703-490-7635
Mailing address:
  • Phone: 301-816-2424
  • Fax: 301-816-2424

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD039292
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberD0072743
License Number StateMD
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0101058776
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: