Provider Demographics
NPI:1285192112
Name:ODOOM, KOBINA
Entity type:Individual
Prefix:
First Name:KOBINA
Middle Name:
Last Name:ODOOM
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 1:1049 DARTMOUTH DR
Mailing Address - Street 2:
Mailing Address - City:BARTLETT
Mailing Address - State:IL
Mailing Address - Zip Code:60103-7514
Mailing Address - Country:US
Mailing Address - Phone:773-403-0338
Mailing Address - Fax:
Practice Address - Street 1:1725 W HARRISON ST STE 207
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3988
Practice Address - Country:US
Practice Address - Phone:312-942-5861
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-11
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.018292363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty