Provider Demographics
NPI:1841946944
Name:SHODIYA, OYEYEMI ANTHONY
Entity type:Individual
Prefix:
First Name:OYEYEMI
Middle Name:ANTHONY
Last Name:SHODIYA
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 1:15928 LECLAIRE AVE APT A206
Mailing Address - Street 2:
Mailing Address - City:OAK FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60452-3911
Mailing Address - Country:US
Mailing Address - Phone:708-864-1818
Mailing Address - Fax:
Practice Address - Street 1:15928 LECLAIRE AVE APT A206
Practice Address - Street 2:
Practice Address - City:OAK FOREST
Practice Address - State:IL
Practice Address - Zip Code:60452-3911
Practice Address - Country:US
Practice Address - Phone:708-864-1818
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-28
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041463053163W00000X
IL209025058363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Multi-Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty