Healthcare Provider Details

I. General information

NPI: 1073877262
Provider Name (Legal Business Name): AGBOOLA AWOMOLO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2012
Last Update Date: 07/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4646 N MARINE DR
CHICAGO IL
60640-5759
US

IV. Provider business mailing address

15537 INGLESIDE AVE
DOLTON IL
60419-2759
US

V. Phone/Fax

Practice location:
  • Phone: 773-878-8700
  • Fax:
Mailing address:
  • Phone: 773-430-1254
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number3694807
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: