Provider Demographics
NPI:1326334459
Name:EDOKPOLO, OSAMEDE (MD)
Entity Type:Individual
Prefix:DR
First Name:OSAMEDE
Middle Name:
Last Name:EDOKPOLO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:NMN
Other - Middle Name:NMN
Other - Last Name:NMN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 2580
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65801-2580
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:
Practice Address - Street 1:620 E MONROE ST
Practice Address - Street 2:
Practice Address - City:MEXICO
Practice Address - State:MO
Practice Address - Zip Code:65265-2919
Practice Address - Country:US
Practice Address - Phone:573-582-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-27
Last Update Date:2020-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20130027732084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO431560263OtherTRICARE
MO1326334459Medicaid
MOP01222578OtherRR MCR
AR198983001Medicaid
AR198983001Medicaid