Basic Information
| Provider Information | |||||||||
| NPI: | 1275820664 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ENILARI | ||||||||
| FirstName: | OLADUNNI | ||||||||
| MiddleName: | MODINAT | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 856 J CLYDE MORRIS BLVD STE A | ||||||||
| Address2: | |||||||||
| City: | NEWPORT NEWS | ||||||||
| State: | VA | ||||||||
| PostalCode: | 236011318 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7573165800 | ||||||||
| FaxNumber: | 7575345190 | ||||||||
| Practice Location | |||||||||
| Address1: | 12200 WARWICK BLVD STE 290 | ||||||||
| Address2: | |||||||||
| City: | NEWPORT NEWS | ||||||||
| State: | VA | ||||||||
| PostalCode: | 236012344 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7575345454 | ||||||||
| FaxNumber: | 7575345491 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2011 | ||||||||
| LastUpdateDate: | 08/26/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/26/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | 2014-01432 | NC | N | Allopathic & Osteopathic Physicians | General Practice | 207RP1001X | 0101266889 | VA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | 1275820664 | 01 | NC | TRICARE | OTHER | 1275820664 | 05 | NC | MEDICAID | 5114141 | 01 | NC | UNITED HEALTHCARE | OTHER | Q0143H | 01 | NC | SC MEDICAID | OTHER | 1275820664 | 01 | VA | VIRGNIA MEDICAID | OTHER | 1869Q | 01 | NC | BCBS | OTHER |