Provider Demographics
NPI:1457302937
Name:OLUSANYA, OLUYOMI O (MD)
Entity Type:Individual
Prefix:
First Name:OLUYOMI
Middle Name:O
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:PO BOX 932051
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64193-0001
Mailing Address - Country:US
Mailing Address - Phone:314-989-0300
Mailing Address - Fax:
Practice Address - Street 1:1060 S BISHOP AVE
Practice Address - Street 2:
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401-4465
Practice Address - Country:US
Practice Address - Phone:573-426-5900
Practice Address - Fax:573-426-4466
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2013-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002009086207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO208747204Medicaid
MO001015168Medicare PIN
MO132130014Medicare PIN
MO001014967Medicare PIN
MOH64516Medicare UPIN
MO046013213Medicare PIN
MO001015401Medicare PIN