Healthcare Provider Details

I. General information

NPI: 1720508666
Provider Name (Legal Business Name): EBUNOLUWA EWERE OTEGBEYE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2017
Last Update Date: 08/05/2025
Certification Date: 08/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1008 S SPRING AVE
SAINT LOUIS MO
63110-2520
US

IV. Provider business mailing address

1008 S SPRING AVE
SAINT LOUIS MO
63110-2520
US

V. Phone/Fax

Practice location:
  • Phone: 314-977-3530
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number2019021293
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: