Healthcare Provider Details

I. General information

NPI: 1487910675
Provider Name (Legal Business Name): AYODEJI OLALEKAN GBOTOSHO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2012
Last Update Date: 04/23/2021
Certification Date: 04/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 E 51ST ST
CHICAGO IL
60615-2400
US

IV. Provider business mailing address

500 E 51ST ST
CHICAGO IL
60615-2400
US

V. Phone/Fax

Practice location:
  • Phone: 312-572-2643
  • Fax: 312-572-2669
Mailing address:
  • Phone: 312-572-2643
  • Fax: 312-572-2669

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036-137013
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: