Provider Demographics
NPI:1104456961
Name:SHODIYA, OLUBUKOLA E
Entity type:Individual
Prefix:
First Name:OLUBUKOLA
Middle Name:E
Last Name:SHODIYA
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8828 S MOZART AVE
Mailing Address - Street 2:
Mailing Address - City:EVERGREEN PK
Mailing Address - State:IL
Mailing Address - Zip Code:60805-1140
Mailing Address - Country:US
Mailing Address - Phone:708-996-9100
Mailing Address - Fax:
Practice Address - Street 1:8828 S MOZART AVE
Practice Address - Street 2:
Practice Address - City:EVERGREEN PK
Practice Address - State:IL
Practice Address - Zip Code:60805-1140
Practice Address - Country:US
Practice Address - Phone:708-996-9100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-21
Last Update Date:2025-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.020728363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209.020728OtherIDFPR
IN71013331AOtherIN APRN