Provider Demographics
NPI:1174592125
Name:ODUNTAN, OLUSOLA (MD)
Entity type:Individual
Prefix:DR
First Name:OLUSOLA
Middle Name:
Last Name:ODUNTAN
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:PO BOX 780
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26507-0780
Mailing Address - Country:US
Mailing Address - Phone:304-285-7101
Mailing Address - Fax:
Practice Address - Street 1:1 MEDICAL CENTER DRIVE
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26506
Practice Address - Country:US
Practice Address - Phone:304-293-4180
Practice Address - Fax:304-293-5845
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2014-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA224064208600000X, 208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAI34796Medicare UPIN