Provider Demographics
NPI:1235664376
Name:IDOWU, MARY BOLUWATIFE (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:BOLUWATIFE
Last Name:IDOWU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:937 ATLANTIC AVE
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23451-3529
Mailing Address - Country:US
Mailing Address - Phone:757-510-9516
Mailing Address - Fax:
Practice Address - Street 1:937 ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23451-3529
Practice Address - Country:US
Practice Address - Phone:757-510-9516
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-26
Last Update Date:2020-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101265340208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice