Healthcare Provider Details

I. General information

NPI: 1033353792
Provider Name (Legal Business Name): TED GEORGE ODY ACHUFUSI DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2009
Last Update Date: 05/27/2026
Certification Date: 05/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31 W 155TH ST
HARVEY IL
60426-3556
US

IV. Provider business mailing address

6738 BLACKSTONE CIR
PORTAGE IN
46368-2693
US

V. Phone/Fax

Practice location:
  • Phone: 708-596-5177
  • Fax: 708-596-5518
Mailing address:
  • Phone: 347-854-8171
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number02004055B
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036129835
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateME
# 4
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number02004055A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: