Provider Demographics
NPI:1477909448
Name:ODUGBESAN, TEMIDAYO OLUGBENGA (MD, SA-C)
Entity Type:Individual
Prefix:DR
First Name:TEMIDAYO
Middle Name:OLUGBENGA
Last Name:ODUGBESAN
Suffix:
Gender:M
Credentials:MD, SA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2024 CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36106-1111
Mailing Address - Country:US
Mailing Address - Phone:334-440-3061
Mailing Address - Fax:
Practice Address - Street 1:78 KENILWORTH CT APT 3S
Practice Address - Street 2:
Practice Address - City:ROMEOVILLE
Practice Address - State:IL
Practice Address - Zip Code:60446-4272
Practice Address - Country:US
Practice Address - Phone:872-806-4250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-10
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL238.000495363AS0400X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical