Healthcare Provider Details

I. General information

NPI: 1487651717
Provider Name (Legal Business Name): OLUYEMISI R. SANGODEYI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2005
Last Update Date: 10/12/2023
Certification Date: 10/12/2023
Deactivation Date: 03/20/2006
Reactivation Date: 04/05/2006

III. Provider practice location address

1902 HARPER RD STE ABC
BECKLEY WV
25801-2642
US

IV. Provider business mailing address

1902 HARPER RD STE ABC
BECKLEY WV
25801-2642
US

V. Phone/Fax

Practice location:
  • Phone: 304-253-3000
  • Fax: 304-255-7884
Mailing address:
  • Phone: 304-253-3000
  • Fax: 304-255-7884

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number21942
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number21942
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: