Provider Demographics
NPI:1891983243
Name:OGUNTOYE, OLATUBOSUN OLASUPO (MD)
Entity type:Individual
Prefix:
First Name:OLATUBOSUN
Middle Name:OLASUPO
Last Name:OGUNTOYE
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 1:1907 W SYCAMORE ST
Mailing Address - Street 2:
Mailing Address - City:KOKOMO
Mailing Address - State:IN
Mailing Address - Zip Code:46901-5148
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1907 W SYCAMORE ST
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46901-5148
Practice Address - Country:US
Practice Address - Phone:765-236-8363
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-11
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS19931208000000X
IN01062399A208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN20091550Medicaid
IN01062399AOtherINDIANA LICENSE