Provider Demographics
NPI:1851946321
Name:OLUFAWO-SOFOLUWE, OLUYINKA
Entity Type:Individual
Prefix:
First Name:OLUYINKA
Middle Name:
Last Name:OLUFAWO-SOFOLUWE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:OLUYINKA
Other - Middle Name:
Other - Last Name:OLUFAWO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1005 HEALTH CENTER DR STE 201
Mailing Address - Street 2:
Mailing Address - City:MATTOON
Mailing Address - State:IL
Mailing Address - Zip Code:61938-4653
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1000 HEALTH CENTER DR
Practice Address - Street 2:
Practice Address - City:MATTOON
Practice Address - State:IL
Practice Address - Zip Code:61938-4644
Practice Address - Country:US
Practice Address - Phone:217-238-4325
Practice Address - Fax:217-348-4920
Is Sole Proprietor?:No
Enumeration Date:2019-08-01
Last Update Date:2023-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-163470208000000X, 208M00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program