Healthcare Provider Details

I. General information

NPI: 1568717510
Provider Name (Legal Business Name): ERNEST AYODELE GBADEBO-GOYEA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/16/2012
Last Update Date: 07/01/2024
Certification Date: 04/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 JEFFERSON BARRACKS DR
SAINT LOUIS MO
63125-4181
US

IV. Provider business mailing address

1111 S LINCOLN AVE UNIT 1563
O FALLON IL
62269-5172
US

V. Phone/Fax

Practice location:
  • Phone: 314-652-4100
  • Fax:
Mailing address:
  • Phone: 618-698-5303
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number00000000
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number336109441
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: