Healthcare Provider Details

I. General information

NPI: 1669586954
Provider Name (Legal Business Name): MOYOSORE KIKELOMO ONIFADE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2006
Last Update Date: 06/19/2024
Certification Date: 06/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2880 NETHERTON DR STE 200
SAINT LOUIS MO
63136-4697
US

IV. Provider business mailing address

2880 NETHERTON DR STE 200
SAINT LOUIS MO
63136-4697
US

V. Phone/Fax

Practice location:
  • Phone: 636-333-4500
  • Fax: 314-521-4656
Mailing address:
  • Phone: 636-333-4500
  • Fax: 314-521-4656

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2002019255
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: