Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Q00000X | Family Doctor | 036084729 | IL |
Y | 207QA0401X | Family Doctor - Addiction Medicine | 036084729 | IL |
NPI | 1760449938 |
---|---|
Provider Name | Dr. Adeyemi Oludare Fatoki |
First Address | Calumet City, IL 60409-5459 |
Second Address | Ottawa, IL 61350-4805 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 28/04/2006 |
Last Update Date | 19/12/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
F05633 | (02) | IL |