Provider Demographics
NPI:1184685802
Name:FADARE, SAMUEL O JR (MD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:O
Last Name:FADARE
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1513 UNION AVE STE 2500
Mailing Address - Street 2:
Mailing Address - City:MOBERLY
Mailing Address - State:MO
Mailing Address - Zip Code:65270-9412
Mailing Address - Country:US
Mailing Address - Phone:660-372-1313
Mailing Address - Fax:660-372-1339
Practice Address - Street 1:5604 NE ANTIOCH RD
Practice Address - Street 2:
Practice Address - City:GLADSTONE
Practice Address - State:MO
Practice Address - Zip Code:64119-2327
Practice Address - Country:US
Practice Address - Phone:660-372-1313
Practice Address - Fax:660-372-1339
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2022-10-06
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
KS04-246722084P0800X
MI43010630062084P0800X
GA903872084P0800X
FLME1571752084P0800X
MO1039392084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100180090FMedicaid
KS04-24672OtherSTATE LICENSE
MO1184685802Medicaid
MO103939OtherSTATE LICENSE (MD)
KS100180090FMedicaid
MO22496091OtherBLUE SHIELD KC, MO
MO206908469Medicaid
KS102598Medicare PIN