Provider Demographics
NPI:1326229121
Name:ADISA, MOTUNRAYO (MD)
Entity type:Individual
Prefix:DR
First Name:MOTUNRAYO
Middle Name:
Last Name:ADISA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 E DELAWARE PL STE 1450
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-6559
Mailing Address - Country:US
Mailing Address - Phone:312-483-4397
Mailing Address - Fax:
Practice Address - Street 1:554 GREEN BAY RD STE E
Practice Address - Street 2:
Practice Address - City:KENILWORTH
Practice Address - State:IL
Practice Address - Zip Code:60043-1086
Practice Address - Country:US
Practice Address - Phone:312-483-4397
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-20
Last Update Date:2025-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036125295207ND0900X, 207N00000X
IL125-052-665207R00000X
MA256848207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine