Provider Demographics
NPI:1417751538
Name:AYEGBUSI, OLUBUKOLA (MD)
Entity type:Individual
Prefix:
First Name:OLUBUKOLA
Middle Name:
Last Name:AYEGBUSI
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 S WALNUT ST APT 5
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-7320
Mailing Address - Country:US
Mailing Address - Phone:630-901-1985
Mailing Address - Fax:
Practice Address - Street 1:207 S WALNUT ST APT 5
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-7320
Practice Address - Country:US
Practice Address - Phone:630-901-1985
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-01
Last Update Date:2025-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program