Healthcare Provider Details

I. General information

NPI: 1114085842
Provider Name (Legal Business Name): EDWARD K KANKAM D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/05/2006
Last Update Date: 10/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

293 NW PEACOCK BLVD STE 101-104
PORT SAINT LUCIE FL
34986-2222
US

IV. Provider business mailing address

293 NW PEACOCK BLVD STE 101-104
PORT SAINT LUCIE FL
34986-2222
US

V. Phone/Fax

Practice location:
  • Phone: 772-335-9600
  • Fax: 772-879-4478
Mailing address:
  • Phone: 772-335-9600
  • Fax: 772-879-4478

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS7965
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: