Oluwaseun Adelanke Adetayo, M.D.
Individual provider Active NPI Plastic Surgery Physician · Loma Linda, CA
NPI 1710190285 · NPPES record last updated Dec 20, 2023
Key facts
- NPI
- 1710190285
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Plastic Surgery Physician 208200000X
- License
- 3829 (WI)
- Practice address
- 11234 Anderson St
Llumc House Staff Office CP 21005
Loma Linda, CA 92354-2804 - Phone
- (909) 558-4000
- NPI assigned
- May 8, 2007
- Sex
- Female
- Sole proprietor
- No
Organizations & group practices 2
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in WI, GA
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: Yes · Hospice: Yes
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20240117002754 | WI | Practitioner - Plastic and Reconstructive Surgery | 6507029444 | Reassigns benefits to 1 organization |
| I20240411001729 | GA | Practitioner - Plastic and Reconstructive Surgery | 6507029444 | Reassigns benefits to 1 organization |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
- Credentials
- Doctor of Medicine
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Thedacare, Incorporated | Current |
Accepting new patients | |
| Phoebe Physician Group, Inc | Current |
Accepting new patients |
Locations
2002 Palmyra Rd
Ste 201
Albany, GA 31701
Phone (229) 312-5802
151 Mayo St
Ste B
Americus, GA 31709
Phone (229) 928-2900
4480 W Spencer St
Appleton, WI 54914
Phone (920) 738-4800
130 2nd St
Neenah, WI 54956
Phone (920) 729-2063
3 Neenah Ctr
Neenah, WI 54956
Phone (920) 454-4229
600 N Westhaven Dr
Oshkosh, WI 54904
Phone (920) 237-5000
Interoperability endpoints
- oadetayo336468@direct.thedacare.org
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Plastic Surgery Physician | 208200000X | 3829 | WI | Yes |
Addresses
Primary practice location
11234 Anderson St
Llumc House Staff Office CP 21005
Loma Linda, CA 92354-2804
Mailing address
11234 Anderson St
Llumc House Staff Office CP 21005
Loma Linda, CA 92354-2804
Other practice location 1
130 2nd St
Neenah, WI 54956-2883
Phone (920) 358-1223
Other providers in Loma Linda, CA
- Matthew W Adams
- Susann Marie Adams
- Amyela Javier Adarlo
- Raychelle Harper Addo
- Adelaida S. Galasinao
- Andranig Andy Adjemian
- Ira Natasha Advani
- Blanca Aespuro
- John C Affeldt
- Ghada Afifi
All providers in Loma Linda, CA · Plastic Surgery Physician in California
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Dec 20, 2023. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.