Provider Demographics
NPI:1699829747
Name:OYETUNDE, SUSAN T (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:T
Last Name:OYETUNDE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:SUSAN
Other - Middle Name:T
Other - Last Name:OYETUNDE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 17578
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60617-0578
Mailing Address - Country:US
Mailing Address - Phone:773-374-2443
Mailing Address - Fax:773-374-7652
Practice Address - Street 1:9135 S EXCHANGE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60617-4225
Practice Address - Country:US
Practice Address - Phone:773-374-2441
Practice Address - Fax:773-374-7652
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2011-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207Q00000X208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036051741Medicaid
IL216-06654OtherBLUE CROSS BLUE SHIELD
ILD89263Medicare UPIN
IL216-06654OtherBLUE CROSS BLUE SHIELD