Healthcare Provider Details

I. General information

NPI: 1235387416
Provider Name (Legal Business Name): OLUSEGUN ADESANYA ODUKOYA M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2008
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11100 EUCLID AVE
CLEVELAND OH
44106-1716
US

IV. Provider business mailing address

24701 EUCLID AVE 3RD FLOOR
EUCLID OH
44117-1714
US

V. Phone/Fax

Practice location:
  • Phone: 216-844-3944
  • Fax: 216-844-8974
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberTP891
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number4301093350
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number35.120134
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: