Healthcare Provider Details

I. General information

NPI: 1932315942
Provider Name (Legal Business Name): DR. M. K. ONIFADE INTERNAL MEDICINE PRACTICE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 10/21/2024
Certification Date: 10/21/2024
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: 314-355-5300
  • Fax: 314-521-4656
Mailing address:
  • Phone: 314-355-5300
  • 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: DR. MOYOSORE KIKELOMO ONIFADE
Title or Position: MANAGER
Credential: M.D.
Phone: 314-355-5300