Healthcare Provider Details

I. General information

NPI: 1063866390
Provider Name (Legal Business Name): KOJO AGYABENG-DADZIE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2016
Last Update Date: 08/08/2023
Certification Date: 08/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 W UNDERWOOD ST FL 4
ORLANDO FL
32806-1110
US

IV. Provider business mailing address

22 W UNDERWOOD ST FL 4
ORLANDO FL
32806-1110
US

V. Phone/Fax

Practice location:
  • Phone: 407-648-5384
  • Fax: 321-843-6285
Mailing address:
  • Phone: 407-648-5384
  • Fax: 321-843-6285

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License NumberME161706
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: