Provider Demographics
NPI:1003381757
Name:OGUNTOBA, SEGUN BABATUNDE (FNP)
Entity Type:Individual
Prefix:
First Name:SEGUN
Middle Name:BABATUNDE
Last Name:OGUNTOBA
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5132 N ELSTON AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60630-2429
Mailing Address - Country:US
Mailing Address - Phone:847-235-6130
Mailing Address - Fax:
Practice Address - Street 1:901 S AUSTIN BLVD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60644-5311
Practice Address - Country:US
Practice Address - Phone:773-287-5959
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-09
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.018124363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily