Provider Demographics
NPI:1861763575
Name:OSHIBANJO, OLA OLAOLUWA
Entity type:Individual
Prefix:MR
First Name:OLA
Middle Name:OLAOLUWA
Last Name:OSHIBANJO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3040 BRAEBURN WAY
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:IL
Mailing Address - Zip Code:60098-2334
Mailing Address - Country:US
Mailing Address - Phone:815-517-2859
Mailing Address - Fax:
Practice Address - Street 1:1845 GRANDSTAND PL
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-6603
Practice Address - Country:US
Practice Address - Phone:847-695-0498
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-26
Last Update Date:2012-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL374700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374700000XNursing Service Related ProvidersTechnician
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL37470000XMedicaid