Healthcare Provider Details

I. General information

NPI: 1700889516
Provider Name (Legal Business Name): ANTHONY OMAVUAYE ODIBO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2005
Last Update Date: 04/25/2024
Certification Date: 09/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4901 FOREST PARK AVE DIV OBGYN MFM AND US, STE 710
SAINT LOUIS MO
63108-1495
US

IV. Provider business mailing address

PO BOX 60352
SAINT LOUIS MO
63160-0352
US

V. Phone/Fax

Practice location:
  • Phone: 314-454-8181
  • Fax: 314-747-1429
Mailing address:
  • Phone: 314-454-8181
  • Fax: 314-747-1429

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License Number2021013428
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: