Provider Demographics
NPI:1467025056
Name:SANGODELE, THEOPHILUS AKINOLA
Entity Type:Individual
Prefix:
First Name:THEOPHILUS
Middle Name:AKINOLA
Last Name:SANGODELE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3219 CLIFTON AVE STE 305
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45220-3047
Mailing Address - Country:US
Mailing Address - Phone:513-346-1270
Mailing Address - Fax:513-489-1526
Practice Address - Street 1:3219 CLIFTON AVE STE 305
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45220-3047
Practice Address - Country:US
Practice Address - Phone:513-346-1270
Practice Address - Fax:513-489-1526
Is Sole Proprietor?:No
Enumeration Date:2021-07-21
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11014429363LP0808X
OH0029670363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health