MEDICARE: LILY O OTOLORIN M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208M00000X	Hospitalist Physician	53928	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	53928	OTHER	WI	WI STATE LIC

General Provider Information

NPI Number	:	1922323435
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LILY O OTOLORIN M.D.

Provider Business Mailing Address
First Line	:	PO BOX 4212
Second Line	:
City	:	WOODBRIDGE
State	:	VA
Zip	:	22194-4212
Country	:	US
Telephone Number	:	646-593-6787
Fax Number	:

Provider Business Practice Location Address
First Line	:	2337 KEW GARDENS DR
Second Line	:
City	:	WOODBRIDGE
State	:	VA
Zip	:	22191-6577
Country	:	US
Telephone Number	:	646-593-6787
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/29/2010
Last Update Date	:	12/06/2016

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