Healthcare Provider Details

I. General information

NPI: 1518412741
Provider Name (Legal Business Name): ELUSEGUN OLOPO DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2016
Last Update Date: 04/06/2021
Certification Date: 02/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 W MARGATE TER APT 1C
CHICAGO IL
60640-3824
US

IV. Provider business mailing address

900 W MARGATE TER APT 1C
CHICAGO IL
60640-3824
US

V. Phone/Fax

Practice location:
  • Phone: 773-556-8569
  • Fax:
Mailing address:
  • Phone: 773-556-8569
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070022490
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: