Healthcare Provider Details

I. General information

NPI: 1023934643
Provider Name (Legal Business Name): OTANGELES MEDICAL OF ILLINOIS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/26/2026
Last Update Date: 06/26/2026
Certification Date: 06/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8 DERBY WAY
BLOOMINGTON IL
61704-2820
US

IV. Provider business mailing address

8 DERBY WAY
BLOOMINGTON IL
61704-2820
US

V. Phone/Fax

Practice location:
  • Phone: 219-256-6002
  • Fax:
Mailing address:
  • Phone: 219-256-6002
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DIONNE C OKAFOR
Title or Position: PRESIDENT
Credential: MD
Phone: 219-256-6002