Provider Demographics
NPI:1760423461
Name:AWOFADEJU, AYOOLA SAMUEL (MD)
Entity Type:Individual
Prefix:
First Name:AYOOLA
Middle Name:SAMUEL
Last Name:AWOFADEJU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3703 BALLANTRAE WAY
Mailing Address - Street 2:
Mailing Address - City:FLOSSMOOR
Mailing Address - State:IL
Mailing Address - Zip Code:60422-4316
Mailing Address - Country:US
Mailing Address - Phone:708-955-6415
Mailing Address - Fax:
Practice Address - Street 1:3703 BALLANTRAE WAY
Practice Address - Street 2:
Practice Address - City:FLOSSMOOR
Practice Address - State:IL
Practice Address - Zip Code:60422-4316
Practice Address - Country:US
Practice Address - Phone:708-955-6415
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-10
Last Update Date:2023-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01063569A207P00000X
IL036102150207R00000X, 207RH0003X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036102150-8Medicaid
P00163002OtherRAILROAD MEDICARE
IL036102150Medicaid
IN200800750Medicaid
H42337Medicare UPIN
IL036102150-8Medicaid
ILH42337Medicare PIN
IL036102150Medicaid
K01472Medicare PIN
IL442760008Medicare PIN