Provider Demographics
NPI:1851966865
Name:OMOTOSHO, OLUWATOSIN GRACE (MD)
Entity type:Individual
Prefix:
First Name:OLUWATOSIN
Middle Name:GRACE
Last Name:OMOTOSHO
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 1:2734 W 87TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60652-3937
Mailing Address - Country:US
Mailing Address - Phone:773-918-4700
Mailing Address - Fax:773-313-3763
Practice Address - Street 1:2734 W 87TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60652-3937
Practice Address - Country:US
Practice Address - Phone:773-918-4700
Practice Address - Fax:773-313-3763
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-21
Last Update Date:2024-07-03
Deactivation Date:2022-11-14
Deactivation Code:
Reactivation Date:2022-12-02
Provider Licenses
StateLicense IDTaxonomies
IL036170232207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine