Provider Demographics
NPI:1972598084
Name:ODUSI, OLATUBOSUN (MD)
Entity Type:Individual
Prefix:
First Name:OLATUBOSUN
Middle Name:
Last Name:ODUSI
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 1:3707 DOTY RD STE H
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:IL
Mailing Address - Zip Code:60098-7530
Mailing Address - Country:US
Mailing Address - Phone:815-206-2800
Mailing Address - Fax:815-337-5491
Practice Address - Street 1:3707 DOTY RD STE H
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:IL
Practice Address - Zip Code:60098-7530
Practice Address - Country:US
Practice Address - Phone:815-206-2800
Practice Address - Fax:815-337-5491
Is Sole Proprietor?:No
Enumeration Date:2005-09-14
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY216736208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1000006625OtherAFFINITY HEALTH
NYP2164401OtherOXFORD HEALTH PLAN
NY216736OtherHIP
NY2C9466OtherHEALTH NET
NY2031247OtherUNITED HEALTH CARE
NY7440270OtherAETNA PPO
NY2592835OtherAETNA USHC PPO
NY2697890OtherGHI
NYOO6736OtherATLANTIS HEALTH PLAN
NY02112912Medicaid
NY112940201OtherHEALTH PLUS
NY0100713-02OtherAMERICHOICE
NY1R0921OtherEMPIRE BCBS
NY216736-A15OtherHEALTH FIRST
NYP2164401OtherOXFORD HEALTH PLAN
NY2592835OtherAETNA USHC PPO