Provider Demographics
NPI:1457044802
Name:OLAGOKE, OLUDELE DAVID
Entity type:Individual
Prefix:
First Name:OLUDELE
Middle Name:DAVID
Last Name:OLAGOKE
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 1:452 MUSKEGON AVE
Mailing Address - Street 2:
Mailing Address - City:CALUMET CITY
Mailing Address - State:IL
Mailing Address - Zip Code:60409-2348
Mailing Address - Country:US
Mailing Address - Phone:312-493-4996
Mailing Address - Fax:
Practice Address - Street 1:452 MUSKEGON AVE
Practice Address - Street 2:
Practice Address - City:CALUMET CITY
Practice Address - State:IL
Practice Address - Zip Code:60409-2348
Practice Address - Country:US
Practice Address - Phone:312-493-4996
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-31
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.029535363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health