MEDICARE: DR. M. K. ONIFADE INTERNAL MEDICINE PRACTICE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	2002019255	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1932315942
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DR. M. K. ONIFADE INTERNAL MEDICINE PRACTICE LLC

Provider Business Mailing Address
First Line	:	2880 NETHERTON DR STE 200
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63136-4697
Country	:	US
Telephone Number	:	314-355-5300
Fax Number	:	314-521-4656

Provider Business Practice Location Address
First Line	:	2880 NETHERTON DR STE 200
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63136-4697
Country	:	US
Telephone Number	:	314-355-5300
Fax Number	:	314-521-4656

Authorized Official
Title or Position	:	MANAGER
Name	:	DR. MOYOSORE KIKELOMO ONIFADE
Credential	:	M.D.
Telephone Number	:	314-355-5300

Provider Enumeration Date	:	05/15/2007
Last Update Date	:	10/21/2024

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