Healthcare Provider Details

I. General information

NPI: 1114272457
Provider Name (Legal Business Name): OWOLABI ADEBAYO SHONUGA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2012
Last Update Date: 09/29/2022
Certification Date: 09/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14605 POTOMAC BRANCH DR
WOODBRIDGE VA
22191
US

IV. Provider business mailing address

14605 POTOMAC BRANCH DR
WOODBRIDGE VA
22191-3336
US

V. Phone/Fax

Practice location:
  • Phone: 703-490-1112
  • Fax: 703-878-8735
Mailing address:
  • Phone: 703-490-1112
  • Fax: 703-878-8735

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0106X
TaxonomyOrthopaedic Hand Surgery Physician
License Number0101264693
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: