Provider Demographics
NPI:1275972432
Name:OSEMWOTA, OSAMUEDE (MD)
Entity Type:Individual
Prefix:
First Name:OSAMUEDE
Middle Name:
Last Name:OSEMWOTA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8000 MARYLAND AVE STE 760
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63105-3752
Mailing Address - Country:US
Mailing Address - Phone:314-474-0114
Mailing Address - Fax:
Practice Address - Street 1:8000 MARYLAND AVE STE 760
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63105-3752
Practice Address - Country:US
Practice Address - Phone:314-474-0114
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-21
Last Update Date:2022-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013019941207N00000X
MO2017039492207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology