Basic Information
| Provider Information | |||||||||
| NPI: | 1164614566 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOFOWOROLA | ||||||||
| FirstName: | OGUNYANKIN | ||||||||
| MiddleName: | OLUFUNSHO | ||||||||
| NamePrefix: | |||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | OGUNYANKIN | ||||||||
| OtherFirstName: | KOFO | ||||||||
| OtherMiddleName: | O | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 680 N LAKE SHORE DR | ||||||||
| Address2: | SUITE 1000 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606114546 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3126959797 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 675 N SAINT CLAIR ST | ||||||||
| Address2: | GALTER 19-100 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606115975 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3126954965 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2007 | ||||||||
| LastUpdateDate: | 08/10/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
No ID Information.