Provider Demographics
NPI:1881143378
Name:OPOKU-OTENG, MARIAN A
Entity type:Individual
Prefix:
First Name:MARIAN
Middle Name:A
Last Name:OPOKU-OTENG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15721 TASSLEFORD LN
Mailing Address - Street 2:101
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22191-6210
Mailing Address - Country:US
Mailing Address - Phone:571-723-7184
Mailing Address - Fax:571-285-2235
Practice Address - Street 1:15721 TASSLEFORD LANE
Practice Address - Street 2:101
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22191
Practice Address - Country:US
Practice Address - Phone:571-723-7184
Practice Address - Fax:571-285-2235
Is Sole Proprietor?:No
Enumeration Date:2016-09-26
Last Update Date:2016-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA464041365171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor