Provider Demographics
NPI:1063483675
Name:ODUYELU, DARLENE RACQUEL (MD)
Entity Type:Individual
Prefix:DR
First Name:DARLENE
Middle Name:RACQUEL
Last Name:ODUYELU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:DARLENE
Other - Middle Name:RACQUEL
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1380 TUSCANY DR
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23456-7751
Mailing Address - Country:US
Mailing Address - Phone:757-252-9780
Mailing Address - Fax:
Practice Address - Street 1:1400 CROSSWAYS BLVD STE 114
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-0207
Practice Address - Country:US
Practice Address - Phone:757-953-6366
Practice Address - Fax:757-953-6056
Is Sole Proprietor?:No
Enumeration Date:2006-01-31
Last Update Date:2019-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101232565207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAH25234Medicare UPIN