MEDICARE: OLANIYI OLADOTUN OSUNTOKUN MD

Medicare Provider Information

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084N0400X	Neurology Physician	01067588A	IN
2	2084P0800X	Psychiatry Physician	35.149699	OH
3	2084P0800X	Psychiatry Physician	04-51796	KS
4	2084P0800X	Psychiatry Physician	S9579	TX
5	2084P0800X	Psychiatry Physician	01067588A	IN
6	2084P0800X	Psychiatry Physician	MD488387C	PA
7	2084P0800X	Psychiatry Physician	55347	KY
8	2084N0400X	Neurology Physician	4301502715	MI

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000704963	OTHER	IN	ANTHEM PIN - GALLAHUE MENTAL HEALTH SERVICES
2	000000704928	OTHER	IN	ANTHEM PIN - SERENITY MEDICAL ASSOCIATES
3	35.149699	OTHER	OH	STATE LICENSURE
4	S9579	OTHER	TX	STATE LICENSURE

NPI Number	:	1548375058
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	OLANIYI OLADOTUN OSUNTOKUN MD

Provider Business Mailing Address
First Line	:	PO BOX 10299
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46851-0299
Country	:	US
Telephone Number	:	574-546-1900
Fax Number	:	574-546-1999

Provider Business Practice Location Address
First Line	:	2100 N MAIN ST STE 304
Second Line	:
City	:	CROWN POINT
State	:	IN
Zip	:	46307-1877
Country	:	US
Telephone Number	:	574-546-1900
Fax Number	:	574-546-1999

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/21/2006
Last Update Date	:	01/16/2026

2243 S 24TH AVE
BROADVIEW, IL
60155-3820

Practice Phone: 708-338-3305
Practice Fax: 708-338-3306

2100 N MAIN ST # 304
CROWN POINT, IN
46307-1877