Basic Information
Provider Information | |||||||||
NPI: | 1700016250 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | OGUNDIMU | ||||||||
FirstName: | OLUSEYI | ||||||||
MiddleName: | FADEGBOLA | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | OGUNDIMU | ||||||||
OtherFirstName: | OLUWASEYI | ||||||||
OtherMiddleName: | FADEGBOLA | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D. | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 190 INDUSTRIAL DR | ||||||||
Address2: |   | ||||||||
City: | FESTUS | ||||||||
State: | MO | ||||||||
PostalCode: | 630284133 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6367772245 | ||||||||
FaxNumber: | 6367772208 | ||||||||
Practice Location | |||||||||
Address1: | 661 FISHER DR | ||||||||
Address2: |   | ||||||||
City: | SULLIVAN | ||||||||
State: | MO | ||||||||
PostalCode: | 630801533 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5738603000 | ||||||||
FaxNumber: | 5738603004 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/17/2009 | ||||||||
LastUpdateDate: | 07/07/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | 2014010100 | MO | Y |   | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 390200000X |   |   | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 207LP2900X | 4301103019 | MI | N |   | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
ID | Type | State | Issuer | Description | 1700016250 | 05 | MO |   | MEDICAID |