Healthcare Provider Details

I. General information

NPI: 1497911267
Provider Name (Legal Business Name): BABATUNDE IDOWU OGUNDIPE MD MPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2008
Last Update Date: 03/30/2022
Certification Date: 03/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 E STATE ST
ROCKFORD IL
61104-1012
US

IV. Provider business mailing address

30 W MONROE ST STE 1200
CHICAGO IL
60603-2420
US

V. Phone/Fax

Practice location:
  • Phone: 815-668-7810
  • Fax:
Mailing address:
  • Phone: 312-733-9730
  • Fax: 773-866-8014

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number35139362
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number4301114259
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number036146080
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: