Provider Demographics
NPI:1487651717
Name:SANGODEYI, OLUYEMISI R (MD)
Entity Type:Individual
Prefix:
First Name:OLUYEMISI
Middle Name:R
Last Name:SANGODEYI
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 1:1902 HARPER RD STE ABC
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801-2642
Mailing Address - Country:US
Mailing Address - Phone:304-253-3000
Mailing Address - Fax:304-255-7884
Practice Address - Street 1:1902 HARPER RD STE ABC
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-2642
Practice Address - Country:US
Practice Address - Phone:304-253-3000
Practice Address - Fax:304-255-7884
Is Sole Proprietor?:No
Enumeration Date:2005-07-01
Last Update Date:2023-10-12
Deactivation Date:2006-03-20
Deactivation Code:
Reactivation Date:2006-04-05
Provider Licenses
StateLicense IDTaxonomies
WV21942208D00000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810016416Medicaid
WV3810016416Medicaid
PA7749905Medicaid
WV3810016416Medicaid