Provider Demographics
NPI:1326557919
Name:OBASEKI, RAY VICTOR
Entity Type:Individual
Prefix:
First Name:RAY
Middle Name:VICTOR
Last Name:OBASEKI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:925 WARWICK DR
Mailing Address - Street 2:
Mailing Address - City:MATTESON
Mailing Address - State:IL
Mailing Address - Zip Code:60443-1998
Mailing Address - Country:US
Mailing Address - Phone:773-983-8005
Mailing Address - Fax:
Practice Address - Street 1:3030 FINLEY RD STE 140
Practice Address - Street 2:
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60515-1179
Practice Address - Country:US
Practice Address - Phone:773-983-8005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-26
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209015745363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily