Basic Information
| Provider Information | |||||||||
| NPI: | 1073877262 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AWOMOLO | ||||||||
| FirstName: | AGBOOLA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15537 INGLESIDE AVE | ||||||||
| Address2: | |||||||||
| City: | DOLTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604192759 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7734301254 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4646 N MARINE DR | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606405759 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7738788700 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2012 | ||||||||
| LastUpdateDate: | 07/02/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 3694807 | IL | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.