Provider Demographics
NPI:1326496613
Name:OLUSANYA, OLUDAYO (MD)
Entity Type:Individual
Prefix:
First Name:OLUDAYO
Middle Name:
Last Name:OLUSANYA
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 1:1011 14TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401-1828
Mailing Address - Country:US
Mailing Address - Phone:580-220-6378
Mailing Address - Fax:580-220-6772
Practice Address - Street 1:1011 14TH AVE NW
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-1828
Practice Address - Country:US
Practice Address - Phone:580-220-6378
Practice Address - Fax:580-220-6772
Is Sole Proprietor?:No
Enumeration Date:2016-05-27
Last Update Date:2023-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK40700207Q00000X
IN11018779A207Q00000X
WI76604207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine