Provider Demographics
NPI:1053790816
Name:KOMOLAFE, GRACE IYABO (MD)
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:IYABO
Last Name:KOMOLAFE
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 1:1000 W HARLEM AVE
Mailing Address - Street 2:
Mailing Address - City:MONMOUTH
Mailing Address - State:IL
Mailing Address - Zip Code:61462-1007
Mailing Address - Country:US
Mailing Address - Phone:309-734-3141
Mailing Address - Fax:309-734-3029
Practice Address - Street 1:1000 W HARLEM AVE
Practice Address - Street 2:
Practice Address - City:MONMOUTH
Practice Address - State:IL
Practice Address - Zip Code:61462-1007
Practice Address - Country:US
Practice Address - Phone:309-734-3141
Practice Address - Fax:309-734-3029
Is Sole Proprietor?:No
Enumeration Date:2015-05-27
Last Update Date:2024-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV28344207P00000X
NY302898207P00000X
NH21826207Q00000X
IL036158512207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine