Provider Demographics
NPI:1538730486
Name:OTUN, AYODAMOLA (MD)
Entity type:Individual
Prefix:
First Name:AYODAMOLA
Middle Name:
Last Name:OTUN
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 1:4466 W PINE BLVD APT 15E
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63108-2338
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9200 W WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-805-8700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-01
Last Update Date:2025-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125079651207T00000X
390200000X
MO2024038099207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program