Provider Demographics
NPI:1528492360
Name:OMOSANYA, IDRIS (PT, DPT)
Entity type:Individual
Prefix:DR
First Name:IDRIS
Middle Name:
Last Name:OMOSANYA
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1750 E 87TH ST STE 103
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60617-2706
Mailing Address - Country:US
Mailing Address - Phone:800-618-6612
Mailing Address - Fax:708-218-9112
Practice Address - Street 1:1750 E 87TH ST STE 103
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60617-2706
Practice Address - Country:US
Practice Address - Phone:708-268-0862
Practice Address - Fax:708-218-9112
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-28
Last Update Date:2019-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070019896225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist