Healthcare Provider Details

I. General information

NPI: 1891004404
Provider Name (Legal Business Name): PRINCE LOLONYO HODOGBEY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2010
Last Update Date: 08/18/2023
Certification Date: 08/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 N LAKE SHORE DR
CHICAGO IL
60657-5640
US

IV. Provider business mailing address

PO BOX 3603
OAK BROOK IL
60522-3603
US

V. Phone/Fax

Practice location:
  • Phone: 312-337-1982
  • Fax: 312-642-3847
Mailing address:
  • Phone: 773-772-7858
  • Fax: 773-276-6668

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036129113
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number125056495
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: