Provider Demographics
NPI:1629234554
Name:EROGBOGBO, ALISSA (MD)
Entity Type:Individual
Prefix:
First Name:ALISSA
Middle Name:
Last Name:EROGBOGBO
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 1:13707 W JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:IL
Mailing Address - Zip Code:60098-3188
Mailing Address - Country:US
Mailing Address - Phone:815-337-1871
Mailing Address - Fax:815-338-6297
Practice Address - Street 1:10350 HALIGUS RD
Practice Address - Street 2:
Practice Address - City:HUNTLEY
Practice Address - State:IL
Practice Address - Zip Code:60142-9558
Practice Address - Country:US
Practice Address - Phone:847-669-3880
Practice Address - Fax:847-669-2980
Is Sole Proprietor?:No
Enumeration Date:2008-07-30
Last Update Date:2009-04-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036121413207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL962341Medicare PIN