Provider Demographics
NPI:1255780342
Name:FANIYAN, OLUMIDE AYODEJI (MBBS, MPH)
Entity type:Individual
Prefix:DR
First Name:OLUMIDE
Middle Name:AYODEJI
Last Name:FANIYAN
Suffix:
Gender:M
Credentials:MBBS, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1901 W HARRISON ST
Mailing Address - Street 2:DEPARTMENT OF PEDIATRICS, ADMINISTRATION BUILDING #1134
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3714
Mailing Address - Country:US
Mailing Address - Phone:312-864-4505
Mailing Address - Fax:
Practice Address - Street 1:1901 W HARRISON ST
Practice Address - Street 2:DEPARTMENT OF PEDIATRICS, ADMINISTRATION BUILDING #1134
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3714
Practice Address - Country:US
Practice Address - Phone:312-864-4505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-09
Last Update Date:2016-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125069281208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics