Healthcare Provider Details

I. General information

NPI: 1316828809
Provider Name (Legal Business Name): WILONDJA AMIMU
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/10/2025
Last Update Date: 10/24/2025
Certification Date: 09/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

673 S KENTWOOD AVE
SPRINGFIELD MO
65802-3229
US

IV. Provider business mailing address

673 S KENTWOOD AVE
SPRINGFIELD MO
65802-3229
US

V. Phone/Fax

Practice location:
  • Phone: 720-350-3109
  • Fax:
Mailing address:
  • Phone: 720-350-3109
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PT0002X
TaxonomyMedical Toxicology (Emergency Medicine) Physician
License Number232002440073
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: