Provider Demographics
NPI:1508468141
Name:OYEDAPO, OLUSOJI TAIWO
Entity Type:Individual
Prefix:
First Name:OLUSOJI
Middle Name:TAIWO
Last Name:OYEDAPO
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 1:17831 FAIROAKS DR
Mailing Address - Street 2:
Mailing Address - City:COUNTRY CLUB HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60478-2929
Mailing Address - Country:US
Mailing Address - Phone:773-225-6904
Mailing Address - Fax:
Practice Address - Street 1:17831 FAIROAKS DR
Practice Address - Street 2:
Practice Address - City:COUNTRY CLUB HILLS
Practice Address - State:IL
Practice Address - Zip Code:60478-2929
Practice Address - Country:US
Practice Address - Phone:773-225-6904
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-09
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL043.128404164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL85-3820733OtherIRS