Provider Demographics
NPI:1285658864
Name:ODUSANYA, YETUNDE OYINLOLA (M D)
Entity Type:Individual
Prefix:DR
First Name:YETUNDE
Middle Name:OYINLOLA
Last Name:ODUSANYA
Suffix:
Gender:F
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:506 MALCOLM X BLVD
Mailing Address - Street 2:W P 522
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10037-1802
Mailing Address - Country:US
Mailing Address - Phone:212-939-2740
Mailing Address - Fax:212-939-2759
Practice Address - Street 1:506 MALCOLM X BLVD
Practice Address - Street 2:W P 522
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10037-1802
Practice Address - Country:US
Practice Address - Phone:212-939-2740
Practice Address - Fax:212-939-2759
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY184195207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01352469Medicaid
NY01Z341Medicare ID - Type Unspecified
NY01352469Medicaid