Provider Demographics
NPI:1477727592
Name:OBATUSIN, TAYO OLUBUNMI (MD)
Entity Type:Individual
Prefix:DR
First Name:TAYO
Middle Name:OLUBUNMI
Last Name:OBATUSIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:571 SAINT JOSEPHS BLVD FL 2
Mailing Address - Street 2:
Mailing Address - City:ELMIRA
Mailing Address - State:NY
Mailing Address - Zip Code:14901-3230
Mailing Address - Country:US
Mailing Address - Phone:607-271-2050
Mailing Address - Fax:607-873-1244
Practice Address - Street 1:555 SAINT JOSEPHS BLVD
Practice Address - Street 2:
Practice Address - City:ELMIRA
Practice Address - State:NY
Practice Address - Zip Code:14901-3223
Practice Address - Country:US
Practice Address - Phone:607-737-7002
Practice Address - Fax:607-271-3435
Is Sole Proprietor?:No
Enumeration Date:2008-04-18
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NE248592084P0802X
NY2493602084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04325288Medicaid
NE10025559200Medicaid
PA103234051Medicaid