Healthcare Provider Details

I. General information

NPI: 1215580816
Provider Name (Legal Business Name): KWABENA OWUSU
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/23/2019
Last Update Date: 07/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 E JOPPA RD STE 106
TOWSON MD
21286-3203
US

IV. Provider business mailing address

205 E JOPPA RD STE 106
TOWSON MD
21286-3203
US

V. Phone/Fax

Practice location:
  • Phone: 410-337-0007
  • Fax:
Mailing address:
  • Phone: 410-337-0007
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberR199760
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: