Provider Demographics
NPI:1881008720
Name:ODUTAYO, OLAIDE
Entity Type:Individual
Prefix:
First Name:OLAIDE
Middle Name:
Last Name:ODUTAYO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2416 S GOEBBERT RD
Mailing Address - Street 2:UNIT 2002
Mailing Address - City:ARLINGTON HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60005-5185
Mailing Address - Country:US
Mailing Address - Phone:224-558-3597
Mailing Address - Fax:
Practice Address - Street 1:2416 S GOEBBERT RD
Practice Address - Street 2:UNIT 2002
Practice Address - City:ARLINGTON HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60005-5185
Practice Address - Country:US
Practice Address - Phone:847-258-3198
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-18
Last Update Date:2014-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL80-0955747Medicare PIN