Provider Demographics
NPI:1669586954
Name:ONIFADE, MOYOSORE KIKELOMO (MD)
Entity type:Individual
Prefix:DR
First Name:MOYOSORE
Middle Name:KIKELOMO
Last Name:ONIFADE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:2880 NETHERTON DR STE 200
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63136-4697
Mailing Address - Country:US
Mailing Address - Phone:636-333-4500
Mailing Address - Fax:314-521-4656
Practice Address - Street 1:2880 NETHERTON DR STE 200
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63136-4697
Practice Address - Country:US
Practice Address - Phone:636-333-4500
Practice Address - Fax:314-521-4656
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-17
Last Update Date:2024-06-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2002019255207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO208818716Medicaid