Healthcare Provider Details

I. General information

NPI: 1932012671
Provider Name (Legal Business Name): KOFFI KING DAVID KEVIN DJIBITO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/24/2026
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10415 HICKORY RIDGE RD
COLUMBIA MD
21044-4633
US

IV. Provider business mailing address

10415 HICKORY RIDGE RD
COLUMBIA MD
21044-4633
US

V. Phone/Fax

Practice location:
  • Phone: 410-831-4690
  • Fax:
Mailing address:
  • Phone: 410-831-4690
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberM07156
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: