Basic Information
| Provider Information | |||||||||
| NPI: | 1679060933 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | IDOWU | ||||||||
| FirstName: | OLUWADAMILOLA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | IDOWU | ||||||||
| OtherFirstName: | DAMILOLA | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 9200 W WISCONSIN AVE | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532263522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4124955645 | ||||||||
| FaxNumber: | 4149550082 | ||||||||
| Practice Location | |||||||||
| Address1: | 9200 W WISCONSIN AVE | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532263522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4124955645 | ||||||||
| FaxNumber: | 4149550082 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2018 | ||||||||
| LastUpdateDate: | 11/04/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207PT0002X | 76660-20 | WI | N | Allopathic & Osteopathic Physicians | Emergency Medicine | Medical Toxicology | 207P00000X | 76660-20 | WI | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1679060933 | 05 | WI | MEDICAID |