Healthcare Provider Details

I. General information

NPI: 1003381757
Provider Name (Legal Business Name): SEGUN BABATUNDE OGUNTOBA FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/09/2018
Last Update Date: 04/28/2021
Certification Date: 04/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 S AUSTIN BLVD
CHICAGO IL
60644-5311
US

IV. Provider business mailing address

5132 N ELSTON AVE
CHICAGO IL
60630-2429
US

V. Phone/Fax

Practice location:
  • Phone: 773-287-5959
  • Fax:
Mailing address:
  • Phone: 847-235-6130
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.018124
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: