Healthcare Provider Details

I. General information

NPI: 1285574517
Provider Name (Legal Business Name): DR. OLATUNJI OLUSEGUN BAMGBOSE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2026
Last Update Date: 03/30/2026
Certification Date: 03/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

818 S WOLCOTT AVE
CHICAGO IL
60612-3702
US

IV. Provider business mailing address

4545 N BEACON ST APT 210
CHICAGO IL
60640-5502
US

V. Phone/Fax

Practice location:
  • Phone: 312-719-1524
  • Fax:
Mailing address:
  • Phone: 312-719-1524
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code261QR1100X
TaxonomyResearch Clinic/Center
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: