Provider Demographics
NPI:1417275033
Name:ADETUYI, OLUSEGUN (MD, MPH)
Entity Type:Individual
Prefix:
First Name:OLUSEGUN
Middle Name:
Last Name:ADETUYI
Suffix:
Gender:M
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3514
Mailing Address - Street 2:
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90277-1514
Mailing Address - Country:US
Mailing Address - Phone:559-572-2583
Mailing Address - Fax:
Practice Address - Street 1:4212 N 16TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-5319
Practice Address - Country:US
Practice Address - Phone:602-263-1200
Practice Address - Fax:602-263-1619
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-06
Last Update Date:2024-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA122119208M00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA122119OtherCA LICENSE