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General NPI Number Information
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NPI Number | 1669586954
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Entity Type | Individual
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Provider Name | MOYOSORE KIKELOMO ONIFADE M.D.
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Gender | Female
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Dates
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Enumeration Date | 08/17/2006
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Last Update Date | 06/19/2024
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Provider Practice Location Address
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Address Line | 2880 NETHERTON DR STE 200
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City | SAINT LOUIS
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State | MO
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Zip | 63136-4697
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Country | US
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Telephone | 636-333-4500
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Fax | 314-521-4656
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Provider Business Mailing Address
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Address Line | 2880 NETHERTON DR STE 200
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City | SAINT LOUIS
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State | MO
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Zip | 63136-4697
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Country | US
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Telephone | 636-333-4500
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Fax | 314-521-4656
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 2002019255
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License Number State | MO
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