Healthcare Provider Details

I. General information

NPI: 1508815762
Provider Name (Legal Business Name): KWAME S. AMANKWAH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2006
Last Update Date: 09/26/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

263 FARMINGTON AVE
FARMINGTON CT
06030-0001
US

IV. Provider business mailing address

263 FARMINGTON AVE
FARMINGTON CT
06030-8082
US

V. Phone/Fax

Practice location:
  • Phone: 860-679-8080
  • Fax: 860-679-1430
Mailing address:
  • Phone: 860-679-8080
  • Fax: 860-679-1430

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number232988
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number232988
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number040506
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: