Healthcare Provider Details

I. General information

NPI: 1205156668
Provider Name (Legal Business Name): OMOLADE AWOLAJA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2010
Last Update Date: 09/22/2025
Certification Date: 09/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2822 E 83RD ST
CHICAGO IL
60617-2105
US

IV. Provider business mailing address

2822 E 83RD ST
CHICAGO IL
60617-2105
US

V. Phone/Fax

Practice location:
  • Phone: 773-721-7600
  • Fax: 773-721-7618
Mailing address:
  • Phone: 773-721-7600
  • Fax: 773-721-7618

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036135594
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: