Provider Demographics
NPI:1790714061
Name:ODISHO, SARGON BENJAMIN (DC)
Entity Type:Individual
Prefix:DR
First Name:SARGON
Middle Name:BENJAMIN
Last Name:ODISHO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:720 DUNHILL DR
Mailing Address - Street 2:
Mailing Address - City:BUFFALO GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60089-1515
Mailing Address - Country:US
Mailing Address - Phone:312-944-4653
Mailing Address - Fax:312-944-0747
Practice Address - Street 1:1360 N SANDBURG TER
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60610-2075
Practice Address - Country:US
Practice Address - Phone:312-944-4653
Practice Address - Fax:312-944-0747
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-30
Last Update Date:2015-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038010338111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor