1972598084 NPI number — OLATUBOSUN ODUSI MD

Table of content: OLATUBOSUN ODUSI MD (NPI 1972598084)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972598084 NPI number — OLATUBOSUN ODUSI MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ODUSI
Provider First Name:
OLATUBOSUN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1972598084
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/14/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3707 DOTY RD STE H
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WOODSTOCK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60098-7530
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-206-2800
Provider Business Mailing Address Fax Number:
815-337-5491

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3707 DOTY RD STE H
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WOODSTOCK
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60098-7530
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-206-2800
Provider Business Practice Location Address Fax Number:
815-337-5491
Provider Enumeration Date:
09/14/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  216736 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1000006625 . This is a "AFFINITY HEALTH" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: P2164401 . This is a "OXFORD HEALTH PLAN" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 216736 . This is a "HIP" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 2C9466 . This is a "HEALTH NET" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 2031247 . This is a "UNITED HEALTH CARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 7440270 . This is a "AETNA PPO" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 2592835 . This is a "AETNA USHC PPO" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 2697890 . This is a "GHI" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: OO6736 . This is a "ATLANTIS HEALTH PLAN" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 02112912 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 112940201 . This is a "HEALTH PLUS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 0100713-02 . This is a "AMERICHOICE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 1R0921 . This is a "EMPIRE BCBS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 216736-A15 . This is a "HEALTH FIRST" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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