=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922597871
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | OMAGBEMI ALEX BUWA MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/07/2018
-----------------------------------------------------
Last Update Date | 03/04/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 600 E 5TH ST
-----------------------------------------------------
City | FULTON
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65251-1793
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-592-4100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 600 E 5TH ST
-----------------------------------------------------
City | FULTON
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65251-1793
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-592-4100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 2021026576
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------