1275820664 NPI number — OLADUNNI MODINAT ENILARI MD

Table of content: OLADUNNI MODINAT ENILARI MD (NPI 1275820664)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275820664 NPI number — OLADUNNI MODINAT ENILARI MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ENILARI
Provider First Name:
OLADUNNI
Provider Middle Name:
MODINAT
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1275820664
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/26/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
856 J CLYDE MORRIS BLVD STE A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEWPORT NEWS
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23601-1318
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-316-5800
Provider Business Mailing Address Fax Number:
757-534-5190

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12200 WARWICK BLVD STE 290
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEWPORT NEWS
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23601-2344
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-534-5454
Provider Business Practice Location Address Fax Number:
757-534-5491
Provider Enumeration Date:
07/06/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208D00000X , with the licence number:  2014-01432 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RP1001X , with the licence number: 0101266889 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1275820664 . This is a "TRICARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 1275820664 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5114141 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: Q0143H . This is a "SC MEDICAID" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 1275820664 . This is a "VIRGNIA MEDICAID" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1869Q . This is a "BCBS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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