Healthcare Provider Details

I. General information

NPI: 1376337378
Provider Name (Legal Business Name): VICTORIA IDOWU
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2025
Last Update Date: 05/29/2025
Certification Date: 05/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2160 S 1ST AVE
MAYWOOD IL
60153-3328
US

IV. Provider business mailing address

2160 S 1ST AVE
MAYWOOD IL
60153-3328
US

V. Phone/Fax

Practice location:
  • Phone: 708-216-4533
  • Fax:
Mailing address:
  • Phone: 708-216-3282
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number125.085751
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: