Provider Demographics
NPI:1104435551
Name:OJO, OLUWAGBENGA AFIAMOYE
Entity type:Individual
Prefix:
First Name:OLUWAGBENGA
Middle Name:AFIAMOYE
Last Name:OJO
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 1:6969 N ASHLAND BLVD UNIT 101
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60626-3354
Mailing Address - Country:US
Mailing Address - Phone:773-807-5133
Mailing Address - Fax:
Practice Address - Street 1:6969 N ASHLAND BLVD UNIT 101
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60626-3354
Practice Address - Country:US
Practice Address - Phone:773-807-5133
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-30
Last Update Date:2020-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILO20064172210172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver