Provider Demographics
NPI:1720395411
Name:ODUSANYA, PAUL OLUWATOYIN (MD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:OLUWATOYIN
Last Name:ODUSANYA
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 1:201 W 30TH ST
Mailing Address - Street 2:APARTMENT 107
Mailing Address - City:BAYONNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07002-1876
Mailing Address - Country:US
Mailing Address - Phone:120-123-8539
Mailing Address - Fax:
Practice Address - Street 1:6308 8TH AVE
Practice Address - Street 2:HOSPITALIST MANAGEMENT GROUP , UNITED HOSPITALS
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53143-5031
Practice Address - Country:US
Practice Address - Phone:201-238-5395
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-02
Last Update Date:2021-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI54880-020208M00000X
WI5488-20207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100012065Medicaid