Provider Demographics
NPI:1164003752
Name:LIGHTHOUSE FAMILY MEDICINE AND WELLNESS PLLC
Entity Type:Organization
Organization Name:LIGHTHOUSE FAMILY MEDICINE AND WELLNESS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:OLUFUNMILOLA
Authorized Official - Middle Name:M
Authorized Official - Last Name:OGBONLOWO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:571-293-2424
Mailing Address - Street 1:19465 DEERFIELD AVE STE 309
Mailing Address - Street 2:
Mailing Address - City:LANSDOWNE
Mailing Address - State:VA
Mailing Address - Zip Code:20176-1705
Mailing Address - Country:US
Mailing Address - Phone:571-293-2424
Mailing Address - Fax:972-947-5370
Practice Address - Street 1:19465 DEERFIELD AVE STE 309
Practice Address - Street 2:
Practice Address - City:LANSDOWNE
Practice Address - State:VA
Practice Address - Zip Code:20176-1705
Practice Address - Country:US
Practice Address - Phone:571-293-2424
Practice Address - Fax:972-947-5370
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-15
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty