Provider Demographics
NPI:1700077799
Name:OYEFESO, OLUMIDE (MD)
Entity Type:Individual
Prefix:
First Name:OLUMIDE
Middle Name:
Last Name:OYEFESO
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:PO BOX 442
Mailing Address - Street 2:
Mailing Address - City:HAYTI
Mailing Address - State:MO
Mailing Address - Zip Code:63851-0442
Mailing Address - Country:US
Mailing Address - Phone:573-359-1372
Mailing Address - Fax:
Practice Address - Street 1:907 E REED ST
Practice Address - Street 2:946 EAST REED STREET
Practice Address - City:HAYTI
Practice Address - State:MO
Practice Address - Zip Code:63851-1242
Practice Address - Country:US
Practice Address - Phone:573-359-1372
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-06
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007020560208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics