Basic Information
| Provider Information | |||||||||
| NPI: | 1427222884 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OMOTOSHO | ||||||||
| FirstName: | WURAOLA | ||||||||
| MiddleName: | IBIYEMI | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 REMINGTON BOULEVARD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | BOLINGBROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604400000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6309142417 | ||||||||
| FaxNumber: | 6309142499 | ||||||||
| Practice Location | |||||||||
| Address1: | 656 N CONVENT | ||||||||
| Address2: | #C | ||||||||
| City: | BOURBONNAIS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 609140000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8159365167 | ||||||||
| FaxNumber: | 8159378246 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/16/2008 | ||||||||
| LastUpdateDate: | 03/24/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 036120926 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 207W00000X | 125047954 | IL | N | Allopathic & Osteopathic Physicians | Ophthalmology |
No ID Information.