Provider Demographics
NPI:1194710483
Name:SANGOSENI, ABIODUN (MD)
Entity type:Individual
Prefix:
First Name:ABIODUN
Middle Name:
Last Name:SANGOSENI
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 66971
Mailing Address - Street 2:DEPT LE
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63166-6971
Mailing Address - Country:US
Mailing Address - Phone:800-968-6866
Mailing Address - Fax:
Practice Address - Street 1:17 GINGER CREEK MDWS
Practice Address - Street 2:
Practice Address - City:GLEN CARBON
Practice Address - State:IL
Practice Address - Zip Code:62034-3508
Practice Address - Country:US
Practice Address - Phone:800-968-6866
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-13
Last Update Date:2007-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
196690OtherBLUE CROSS BLUE SHIELD
ILH21614Medicare UPIN
MOH21614Medicare UPIN
ILK17989Medicare ID - Type Unspecified