Provider Demographics
NPI:1093100893
Name:ADEGBORO, OLATOKUNBO (MD)
Entity Type:Individual
Prefix:
First Name:OLATOKUNBO
Middle Name:
Last Name:ADEGBORO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 ADELINE ST
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94607-2608
Mailing Address - Country:US
Mailing Address - Phone:510-835-9610
Mailing Address - Fax:
Practice Address - Street 1:4009 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613-2110
Practice Address - Country:US
Practice Address - Phone:773-388-1600
Practice Address - Fax:773-388-8664
Is Sole Proprietor?:No
Enumeration Date:2015-03-30
Last Update Date:2021-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA146952207Q00000X
IL036.156485207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036.156485Medicaid