Healthcare Provider Details

I. General information

NPI: 1790952836
Provider Name (Legal Business Name): KOYEJO A. OYERINDE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2008
Last Update Date: 04/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2111 LANDMARK CIR
MINOT ND
58703-1967
US

IV. Provider business mailing address

PO BOX 997
BISMARCK ND
58502-0997
US

V. Phone/Fax

Practice location:
  • Phone: 701-858-1800
  • Fax: 701-857-8056
Mailing address:
  • Phone: 701-858-1800
  • Fax: 701-857-8056

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number13901
License Number StateND

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1465948
Identifier TypeMEDICAID
Identifier StateND
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: