Provider Demographics
NPI:1154506061
Name:SHADOL LLC
Entity Type:Organization
Organization Name:SHADOL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:OLUMIDE
Authorized Official - Middle Name:
Authorized Official - Last Name:OYEFESO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-300-4515
Mailing Address - Street 1:1800 TRUMAN BLVD
Mailing Address - Street 2:APT 11
Mailing Address - City:CARUTHERSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63830-2425
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:907 E REED ST
Practice Address - Street 2:
Practice Address - City:HAYTI
Practice Address - State:MO
Practice Address - Zip Code:63851-1242
Practice Address - Country:US
Practice Address - Phone:573-359-3660
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-09
Last Update Date:2008-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty