Provider Demographics
NPI:1164604138
Name:OBISESAN, ADEKUNLE OLUWATOSIN (MD)
Entity Type:Individual
Prefix:DR
First Name:ADEKUNLE
Middle Name:OLUWATOSIN
Last Name:OBISESAN
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:625 S NEW BALLAS RD STE 7020
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8218
Mailing Address - Country:US
Mailing Address - Phone:314-251-6486
Mailing Address - Fax:314-251-4155
Practice Address - Street 1:625 S NEW BALLAS RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8240
Practice Address - Country:US
Practice Address - Phone:314-251-6486
Practice Address - Fax:314-251-4155
Is Sole Proprietor?:No
Enumeration Date:2007-12-03
Last Update Date:2022-07-06
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MO2022012233207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1164604138Medicaid