Provider Demographics
NPI:1417944091
Name:IDUSUYI, OSARETIN B (MD)
Entity type:Individual
Prefix:
First Name:OSARETIN
Middle Name:B
Last Name:IDUSUYI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1118 HAMPSHIRE ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301-3027
Mailing Address - Country:US
Mailing Address - Phone:217-222-6550
Mailing Address - Fax:217-277-2253
Practice Address - Street 1:1118 HAMPSHIRE ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301-3027
Practice Address - Country:US
Practice Address - Phone:217-222-6550
Practice Address - Fax:217-277-2253
Is Sole Proprietor?:No
Enumeration Date:2005-09-29
Last Update Date:2024-08-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036095609207X00000X, 207XX0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle Surgery
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036095609Medicaid
IL036095609Medicaid
F45060Medicare UPIN