Provider Demographics
NPI:1164154878
Name:OMO-EBOH, OMOVAUDO DIVINE (MD)
Entity Type:Individual
Prefix:
First Name:OMOVAUDO
Middle Name:DIVINE
Last Name:OMO-EBOH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:FATIMA
Other - Middle Name:
Other - Last Name:OGAR-EGBOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1625 E 75TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60649-3603
Mailing Address - Country:US
Mailing Address - Phone:773-947-7313
Mailing Address - Fax:
Practice Address - Street 1:1625 E 75TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60649-3603
Practice Address - Country:US
Practice Address - Phone:773-947-7313
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-30
Last Update Date:2022-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.081017207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine