Healthcare Provider Details

I. General information

NPI: 1578650941
Provider Name (Legal Business Name): FRED M DONKOH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/06/2006
Last Update Date: 03/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 GRAND ST
HARTFORD CT
06106-1541
US

IV. Provider business mailing address

21 GRAND ST
HARTFORD CT
06106-1541
US

V. Phone/Fax

Practice location:
  • Phone: 860-550-7500
  • Fax: 860-550-7515
Mailing address:
  • Phone: 860-550-7500
  • Fax: 860-550-7515

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number181815
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: