Healthcare Provider Details

I. General information

NPI: 1568753481
Provider Name (Legal Business Name): ADEGOKE OLAOLU ADELEKE I M.D., M.S.M
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2011
Last Update Date: 01/06/2023
Certification Date: 01/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 E. HIGHWAY 60
MOUNTAIN VIEW MO
65548-7381
US

IV. Provider business mailing address

PO BOX 505164
SAINT LOUIS MO
63150-5164
US

V. Phone/Fax

Practice location:
  • Phone: 417-934-2251
  • Fax: 417-934-2871
Mailing address:
  • Phone: 417-820-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2015000034
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberS5109
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: