Healthcare Provider Details

I. General information

NPI: 1093100893
Provider Name (Legal Business Name): OLATOKUNBO ADEGBORO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2015
Last Update Date: 07/26/2021
Certification Date: 07/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4009 N BROADWAY ST
CHICAGO IL
60613-2110
US

IV. Provider business mailing address

700 ADELINE ST
OAKLAND CA
94607-2608
US

V. Phone/Fax

Practice location:
  • Phone: 773-388-1600
  • Fax: 773-388-8664
Mailing address:
  • Phone: 510-835-9610
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA146952
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036.156485
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: