Provider Demographics
NPI:1073958906
Name:BODE-OMOLEYE, OLAOLUWA O (MD, MPH)
Entity Type:Individual
Prefix:DR
First Name:OLAOLUWA
Middle Name:O
Last Name:BODE-OMOLEYE
Suffix:
Gender:M
Credentials:MD, MPH
Other - Prefix:DR
Other - First Name:OLAOLUWA
Other - Middle Name:O
Other - Last Name:BODE-OMOLEYE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:840 S WOOD ST.
Mailing Address - Street 2:RM 130CSN, MC 847
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-4325
Mailing Address - Country:US
Mailing Address - Phone:312-996-7312
Mailing Address - Fax:
Practice Address - Street 1:840 S WOOD ST.
Practice Address - Street 2:RM 130CSN, MC 847
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-4325
Practice Address - Country:US
Practice Address - Phone:312-996-7312
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-06
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036149602207ZD0900X, 207ZH0000X, 207ZP0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology
No207ZD0900XAllopathic & Osteopathic PhysiciansPathologyDermatopathology
No207ZH0000XAllopathic & Osteopathic PhysiciansPathologyHematology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036.149602OtherILLINOIS STATE DEPARTMENT OF FINANCIAL AND PROFESSIONAL REGULATION