Provider Demographics
NPI:1750397725
Name:ODUTOLA, JENNIFER (MD)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:
Last Name:ODUTOLA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:224D CORNWALL ST NW STE 403
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20176-2704
Mailing Address - Country:US
Mailing Address - Phone:703-443-6717
Mailing Address - Fax:703-443-8643
Practice Address - Street 1:19500 SANDRIDGE WAY STE 170
Practice Address - Street 2:
Practice Address - City:LANSDOWNE
Practice Address - State:VA
Practice Address - Zip Code:20176-3692
Practice Address - Country:US
Practice Address - Phone:703-723-3398
Practice Address - Fax:703-723-7464
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0101234395207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1750397725Medicaid
VAVV9035AMedicare PIN
VAI48025Medicare UPIN