Healthcare Provider Details

I. General information

NPI: 1053847780
Provider Name (Legal Business Name): FAFA HUBERTA KOUDORO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2017
Last Update Date: 04/24/2026
Certification Date: 04/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1260 SILAS DEANE HWY STE 104
WETHERSFIELD CT
06109-4363
US

IV. Provider business mailing address

100 HAZARD AVE STE 100
ENFIELD CT
06082-5447
US

V. Phone/Fax

Practice location:
  • Phone: 860-289-3375
  • Fax:
Mailing address:
  • Phone: 860-289-3375
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number72410
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: