Provider Demographics
NPI:1235387416
Name:ODUKOYA, OLUSEGUN ADESANYA (MD)
Entity Type:Individual
Prefix:DR
First Name:OLUSEGUN
Middle Name:ADESANYA
Last Name:ODUKOYA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24701 EUCLID AVE
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44117-1714
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11100 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44106-1716
Practice Address - Country:US
Practice Address - Phone:216-844-3944
Practice Address - Fax:216-844-8974
Is Sole Proprietor?:No
Enumeration Date:2008-08-30
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYTP891207QA0505X
MI4301093350207QA0505X
OH35.120134207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000637130OtherANTHEM BCBS
KY7100104620Medicaid
KYP00773148OtherRR MEDICARE
KY000000637135OtherANTHEM BCBS
OH3009952Medicaid
KYP00773148OtherRR MEDICARE
OHH159130Medicare PIN
KY000000637130OtherANTHEM BCBS