Provider Demographics
NPI:1124730692
Name:OPPONG, SAMUEL
Entity type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:
Last Name:OPPONG
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 1:6305 WOODWARD AVE
Mailing Address - Street 2:
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60516-2311
Mailing Address - Country:US
Mailing Address - Phone:630-506-3530
Mailing Address - Fax:
Practice Address - Street 1:6305 WOODWARD AVE
Practice Address - Street 2:
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60516-2311
Practice Address - Country:US
Practice Address - Phone:630-506-3530
Practice Address - Fax:630-512-0895
Is Sole Proprietor?:No
Enumeration Date:2022-12-15
Last Update Date:2022-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL015278076119172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL871289761Medicaid