Healthcare Provider Details

I. General information

NPI: 1013651074
Provider Name (Legal Business Name): RUKAYAT OLUBUNMI OTULANA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2022
Last Update Date: 07/15/2025
Certification Date: 07/15/2025
Deactivation Date: 01/30/2023
Reactivation Date: 02/28/2023

III. Provider practice location address

698 FEATHERSTONE RD # 250
ROCKFORD IL
61107-6303
US

IV. Provider business mailing address

698 FEATHERSTONE RD # 250
ROCKFORD IL
61107-6303
US

V. Phone/Fax

Practice location:
  • Phone: 815-399-4404
  • Fax:
Mailing address:
  • Phone: 815-399-4404
  • 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 Code207R00000X
TaxonomyInternal Medicine Physician
License Number036175322
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: