Provider Demographics
NPI:1962371740
Name:ADEAGBO, OLUYEMI SAMSON
Entity type:Individual
Prefix:
First Name:OLUYEMI
Middle Name:SAMSON
Last Name:ADEAGBO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9345 KILREA DR
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60462-1131
Mailing Address - Country:US
Mailing Address - Phone:773-681-2487
Mailing Address - Fax:
Practice Address - Street 1:1319 BUTTERFIELD RD STE 500
Practice Address - Street 2:
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60515-5621
Practice Address - Country:US
Practice Address - Phone:414-690-0069
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-31
Last Update Date:2025-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.032399363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health