Provider Demographics
NPI:1548375058
Name:OSUNTOKUN, OLANIYI OLADOTUN (MD)
Entity type:Individual
Prefix:
First Name:OLANIYI
Middle Name:OLADOTUN
Last Name:OSUNTOKUN
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 10299
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46851-0299
Mailing Address - Country:US
Mailing Address - Phone:574-546-1900
Mailing Address - Fax:574-546-1999
Practice Address - Street 1:2100 N MAIN ST STE 304
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-1877
Practice Address - Country:US
Practice Address - Phone:574-546-1900
Practice Address - Fax:574-546-1999
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01067588A2084N0400X, 2084P0800X
OH35.1496992084P0800X
TXS95792084P0800X
KY553472084P0800X
MI43015027152084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000704963OtherANTHEM PIN - GALLAHUE MENTAL HEALTH SERVICES
IN000000704928OtherANTHEM PIN - SERENITY MEDICAL ASSOCIATES
OH35.149699OtherSTATE LICENSURE
TXS9579OtherSTATE LICENSURE