Provider Demographics
NPI:1497996425
Name:OLATUNJI, MOSES O (MD)
Entity Type:Individual
Prefix:
First Name:MOSES
Middle Name:O
Last Name:OLATUNJI
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 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11115 PARKVIEW PLAZA DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1701
Practice Address - Country:US
Practice Address - Phone:260-672-4000
Practice Address - Fax:260-672-6459
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-22
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01069915A208M00000X
IN01066506A2080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036087242Medicaid
IN000000641381OtherANTHEM
IN200937490Medicaid