Provider Demographics
NPI:1023173895
Name:ODELUGA, KANAYO K (MD, MPH)
Entity type:Individual
Prefix:
First Name:KANAYO
Middle Name:K
Last Name:ODELUGA
Suffix:
Gender:M
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:915 W CHICAGO AVE
Mailing Address - Street 2:
Mailing Address - City:EAST CHICAGO
Mailing Address - State:IN
Mailing Address - Zip Code:46312-3308
Mailing Address - Country:US
Mailing Address - Phone:219-397-6000
Mailing Address - Fax:219-397-6358
Practice Address - Street 1:915 W CHICAGO AVE
Practice Address - Street 2:
Practice Address - City:EAST CHICAGO
Practice Address - State:IN
Practice Address - Zip Code:46312
Practice Address - Country:US
Practice Address - Phone:219-397-6000
Practice Address - Fax:219-397-6358
Is Sole Proprietor?:No
Enumeration Date:2006-12-22
Last Update Date:2013-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01047947207R00000X, 2083P0500X, 208D00000X
IL036092504207R00000X, 2083P0500X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No2083P0500XAllopathic & Osteopathic PhysiciansPreventive MedicinePreventive Medicine/Occupational Environmental Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000D93250OtherANTHEM BCBS
IL036092504OtherIL DEPT OF HEALTHCARE & F
080148350OtherPALMETTO GBA MEDI
10593989OtherCAQH
IN200195020Medicaid
IN01047947OtherLICENSING BOARD
IL036092504OtherIL DEPT OF HEALTHCARE & F
IN200195020Medicaid