Provider Demographics
NPI:1831411891
Name:ODUGBESAN, JULIA CAROL (PA-C)
Entity type:Individual
Prefix:MS
First Name:JULIA
Middle Name:CAROL
Last Name:ODUGBESAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JULIA
Other - Middle Name:
Other - Last Name:FRYE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1501 S CALIFORNIA AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60608-1732
Mailing Address - Country:US
Mailing Address - Phone:773-257-6843
Mailing Address - Fax:
Practice Address - Street 1:3537 PAYSHERE CIR
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60674-0001
Practice Address - Country:US
Practice Address - Phone:708-786-2900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-18
Last Update Date:2017-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10001672A363A00000X
IL085-002821363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant