Provider Demographics
NPI:1679060933
Name:IDOWU-ELLSWORTH, DAMILOLA (MD)
Entity type:Individual
Prefix:
First Name:DAMILOLA
Middle Name:
Last Name:IDOWU-ELLSWORTH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:DAMILOLA
Other - Middle Name:
Other - Last Name:IDOWU
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:9200 W WISCONSIN AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3522
Mailing Address - Country:US
Mailing Address - Phone:412-495-5645
Mailing Address - Fax:414-955-0082
Practice Address - Street 1:9200 W WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:412-495-5645
Practice Address - Fax:414-955-0082
Is Sole Proprietor?:No
Enumeration Date:2018-04-21
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI76660-20207P00000X, 207PT0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PT0002XAllopathic & Osteopathic PhysiciansEmergency MedicineMedical Toxicology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1679060933Medicaid