Healthcare Provider Details

I. General information

NPI: 1275285124
Provider Name (Legal Business Name): OLASUMBO ELIZABETH FAGBENLE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/21/2022
Last Update Date: 01/21/2022
Certification Date: 01/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3015 N BALLAS RD
SAINT LOUIS MO
63131-2329
US

IV. Provider business mailing address

1602 ENCLAVE PKWY APT 1708
HOUSTON TX
77077-3616
US

V. Phone/Fax

Practice location:
  • Phone: 954-477-0101
  • Fax:
Mailing address:
  • Phone: 954-477-0101
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2021047578
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2021047578
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: