Provider Demographics
NPI:1376503250
Name:LIPEDE, ADELUOLA G (MD)
Entity Type:Individual
Prefix:DR
First Name:ADELUOLA
Middle Name:G
Last Name:LIPEDE
Suffix:
Gender:M
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:PO BOX 3980
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63006-3980
Mailing Address - Country:US
Mailing Address - Phone:314-522-1888
Mailing Address - Fax:314-522-9674
Practice Address - Street 1:9231 W FLORISSANT AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63136-1422
Practice Address - Country:US
Practice Address - Phone:314-522-1888
Practice Address - Fax:314-522-9674
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR7F89208600000X, 208D00000X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOA02102Medicare UPIN