Provider Demographics
NPI:1407092927
Name:ADERIBIGBE, MODUPE ADEDAMOLA (DPM)
Entity Type:Individual
Prefix:DR
First Name:MODUPE
Middle Name:ADEDAMOLA
Last Name:ADERIBIGBE
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5471 DR MARTIN LUTHER KING DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63112-4265
Mailing Address - Country:US
Mailing Address - Phone:314-367-5820
Mailing Address - Fax:314-367-7010
Practice Address - Street 1:5471 DR MARTIN LUTHER KING DR
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63112-4265
Practice Address - Country:US
Practice Address - Phone:314-367-5820
Practice Address - Fax:314-367-7010
Is Sole Proprietor?:No
Enumeration Date:2009-01-06
Last Update Date:2014-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901002232213EP1101X, 213ES0103X
IL016005470213E00000X
MO2011018632213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO149630004Medicare PIN
IL560770007Medicare PIN
MO149620003Medicare PIN
MOP01050093Medicare PIN
ILP01050086Medicare PIN
IL560750012Medicare PIN