Provider Demographics
NPI:1124434964
Name:SOFOWORA, KOLAWOLE OLUFEMI DOMINIK (MD)
Entity type:Individual
Prefix:DR
First Name:KOLAWOLE
Middle Name:OLUFEMI DOMINIK
Last Name:SOFOWORA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:370 SUMMIT ST
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60120
Mailing Address - Country:US
Mailing Address - Phone:847-608-1344
Mailing Address - Fax:314-454-4102
Practice Address - Street 1:165 E PLANK RD
Practice Address - Street 2:
Practice Address - City:SYCAMORE
Practice Address - State:IL
Practice Address - Zip Code:60178
Practice Address - Country:US
Practice Address - Phone:815-363-9400
Practice Address - Fax:314-454-4102
Is Sole Proprietor?:No
Enumeration Date:2014-07-01
Last Update Date:2017-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.142733208000000X
MO2014019161208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics