Provider Demographics
NPI:1700887486
Name:OMOJOKUN, MORAYO O (MD)
Entity type:Individual
Prefix:DR
First Name:MORAYO
Middle Name:O
Last Name:OMOJOKUN
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 1:1800 TOWN CENTER DR STE 311
Mailing Address - Street 2:
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20190-3239
Mailing Address - Country:US
Mailing Address - Phone:703-763-2705
Mailing Address - Fax:
Practice Address - Street 1:1800 TOWN CENTER DR STE 311
Practice Address - Street 2:
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190-3239
Practice Address - Country:US
Practice Address - Phone:703-763-2705
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-03
Last Update Date:2022-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101238066207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1017449Medicaid
VA178130OtherANTHEM BC/BS