Provider Demographics
NPI:1548377559
Name:ADESIDA, PATIENCE OKPAKU (MD)
Entity type:Individual
Prefix:DR
First Name:PATIENCE
Middle Name:OKPAKU
Last Name:ADESIDA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:PATIENCE
Other - Middle Name:OTUEDON
Other - Last Name:OKPAKU
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2008 N MARKET ST
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61822-1308
Mailing Address - Country:US
Mailing Address - Phone:217-239-6667
Mailing Address - Fax:217-239-6670
Practice Address - Street 1:2008 N MARKET ST
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61822-1308
Practice Address - Country:US
Practice Address - Phone:217-239-6667
Practice Address - Fax:217-239-6670
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-24
Last Update Date:2013-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036075310207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL173634OtherPERSONAL CARE HMO
IL036075310Medicaid
IL01027388OtherBLUE CROSS BLUE SHIELD
IL173634OtherPERSONAL CARE HMO
IL036075310Medicaid