Healthcare Provider Details

I. General information

NPI: 1295933349
Provider Name (Legal Business Name): KOFI DELA QUIST MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2007
Last Update Date: 12/04/2023
Certification Date: 12/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8051 S EMERSON AVE STE 350
INDIANAPOLIS IN
46237-8634
US

IV. Provider business mailing address

6983 HILLSDALE CT
INDIANAPOLIS IN
46250-2054
US

V. Phone/Fax

Practice location:
  • Phone: 317-859-1020
  • Fax: 317-859-4040
Mailing address:
  • Phone: 317-849-8350
  • Fax: 317-576-6311

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number01078024A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: