Healthcare Provider Details

I. General information

NPI: 1487612370
Provider Name (Legal Business Name): JUSTIN O OGBEVOEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2006
Last Update Date: 04/17/2025
Certification Date: 09/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1225 GRAHAM RD DIV PED EMERGENCY MED
FLORISSANT MO
63031-8012
US

IV. Provider business mailing address

PO BOX 7412011
CHICAGO IL
60674-2011
US

V. Phone/Fax

Practice location:
  • Phone: 314-454-2341
  • Fax: 314-454-4345
Mailing address:
  • Phone: 314-454-2341
  • Fax: 314-454-4345

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number103771
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License Number103771
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: