Healthcare Provider Details

I. General information

NPI: 1639521420
Provider Name (Legal Business Name): JEFFREY KOFI TWUM-AMPOFO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2016
Last Update Date: 10/07/2024
Certification Date: 10/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

180 N PARK TRL STE 100
STOCKBRIDGE GA
30281-7372
US

IV. Provider business mailing address

180 N PARK TRL STE 100
STOCKBRIDGE GA
30281-7372
US

V. Phone/Fax

Practice location:
  • Phone: 770-474-5281
  • Fax: 770-389-8674
Mailing address:
  • Phone: 770-474-5281
  • Fax: 770-389-8674

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number88810
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: