Provider Demographics
NPI:1679594030
Name:OJEDIRAN, OLUMUYIWA AKINNIYI (MD)
Entity Type:Individual
Prefix:
First Name:OLUMUYIWA
Middle Name:AKINNIYI
Last Name:OJEDIRAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:734 S SYCAMORE STREET
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23803
Mailing Address - Country:US
Mailing Address - Phone:804-733-0111
Mailing Address - Fax:804-733-1176
Practice Address - Street 1:734 SOUTH SYCAMORE STREET
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23803
Practice Address - Country:US
Practice Address - Phone:804-733-0111
Practice Address - Fax:804-733-1176
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101233648207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAH90675Medicare UPIN