1720395411 NPI number — DR. PAUL OLUWATOYIN ODUSANYA MD

Table of content: DR. PAUL OLUWATOYIN ODUSANYA MD (NPI 1720395411)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720395411 NPI number — DR. PAUL OLUWATOYIN ODUSANYA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ODUSANYA
Provider First Name:
PAUL
Provider Middle Name:
OLUWATOYIN
Provider Name Prefix Text:
DR.
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:
1720395411
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/22/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
201 W 30TH ST
Provider Second Line Business Mailing Address:
APARTMENT 107
Provider Business Mailing Address City Name:
BAYONNE
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07002-1876
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
120-123-8539
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6308 8TH AVE
Provider Second Line Business Practice Location Address:
HOSPITALIST MANAGEMENT GROUP , UNITED HOSPITALS
Provider Business Practice Location Address City Name:
KENOSHA
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53143-5031
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
201-238-5395
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/02/2010

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: 208M00000X , with the licence number:  54880-020 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: 5488-20 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100012065 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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