Healthcare Provider Details

I. General information

NPI: 1538461421
Provider Name (Legal Business Name): ESSIE KUEBERUWA YATES MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ESSIE KUEBERUWA MD

II. Dates (important events)

Enumeration Date: 11/26/2010
Last Update Date: 09/20/2023
Certification Date: 09/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

407 SE 24TH ST
FORT LAUDERDALE FL
33316-3915
US

IV. Provider business mailing address

407 SE 24TH ST
FORT LAUDERDALE FL
33316-3915
US

V. Phone/Fax

Practice location:
  • Phone: 954-463-5208
  • Fax: 954-463-5288
Mailing address:
  • Phone: 954-463-5208
  • Fax: 954-463-5288

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number125057593
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberME126632
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: