Provider Demographics
NPI:1811483928
Name:OYEGUNLE, OLIVIA (OD)
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:
Last Name:OYEGUNLE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1950 OLD GALLOWS RD STE 520
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3970
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:571-223-6780
Practice Address - Street 1:1013 E FREEWAY DR SE
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30094-5965
Practice Address - Country:US
Practice Address - Phone:770-922-7908
Practice Address - Fax:770-483-0498
Is Sole Proprietor?:No
Enumeration Date:2018-07-02
Last Update Date:2022-04-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GAOPT003092152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist