Provider Demographics
NPI:1538254511
Name:IDOWU, OLUMUYIWA (MD)
Entity type:Individual
Prefix:
First Name:OLUMUYIWA
Middle Name:
Last Name:IDOWU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:840 W IRVING PARK RD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-3011
Mailing Address - Country:US
Mailing Address - Phone:773-871-5150
Mailing Address - Fax:773-871-5153
Practice Address - Street 1:840 W IRVING PARK RD
Practice Address - Street 2:STE 204
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613-3011
Practice Address - Country:US
Practice Address - Phone:773-871-5150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2023-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-098784207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036098784Medicaid
IL20167Medicare UPIN