Provider Demographics
NPI:1376748426
Name:LOUDOUN RHEUMATOLOGY CENTER, PC
Entity Type:Organization
Organization Name:LOUDOUN RHEUMATOLOGY CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:ODUTOLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-723-3398
Mailing Address - Street 1:19500 SANDRIDGE WAY STE 170
Mailing Address - Street 2:
Mailing Address - City:LANSDOWNE
Mailing Address - State:VA
Mailing Address - Zip Code:20176-3692
Mailing Address - Country:US
Mailing Address - Phone:703-723-3398
Mailing Address - Fax:703-723-9128
Practice Address - Street 1:19465 DEERFIELD AVE
Practice Address - Street 2:SUITE 309
Practice Address - City:LANSDOWNE
Practice Address - State:VA
Practice Address - Zip Code:20176-8446
Practice Address - Country:US
Practice Address - Phone:703-723-3398
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-19
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101234395207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1376748426Medicaid