Provider Demographics
NPI:1700016250
Name:OGUNDIMU, OLUSEYI FADEGBOLA (MD)
Entity Type:Individual
Prefix:DR
First Name:OLUSEYI
Middle Name:FADEGBOLA
Last Name:OGUNDIMU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:OLUWASEYI
Other - Middle Name:FADEGBOLA
Other - Last Name:OGUNDIMU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:190 INDUSTRIAL DR
Mailing Address - Street 2:
Mailing Address - City:FESTUS
Mailing Address - State:MO
Mailing Address - Zip Code:63028-4133
Mailing Address - Country:US
Mailing Address - Phone:636-777-2245
Mailing Address - Fax:636-777-2208
Practice Address - Street 1:661 FISHER DR
Practice Address - Street 2:
Practice Address - City:SULLIVAN
Practice Address - State:MO
Practice Address - Zip Code:63080-1533
Practice Address - Country:US
Practice Address - Phone:573-860-3000
Practice Address - Fax:573-860-3004
Is Sole Proprietor?:No
Enumeration Date:2009-07-17
Last Update Date:2014-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014010100207LP2900X
390200000X
MI4301103019207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1700016250Medicaid
MOMA2027023Medicare PIN
MO137740031Medicare PIN
MO1700016250Medicaid