Healthcare Provider Details

I. General information

NPI: 1558332833
Provider Name (Legal Business Name): YAW ADJEI OWUSU-ADDO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2006
Last Update Date: 08/20/2020
Certification Date: 08/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 SUMMIT CROSSING PL STE 204
GASTONIA NC
28054-2138
US

IV. Provider business mailing address

640 SUMMIT CROSSING PL STE 240
GASTONIA NC
28054-2138
US

V. Phone/Fax

Practice location:
  • Phone: 704-865-0626
  • Fax: 704-865-6531
Mailing address:
  • Phone: 704-865-0626
  • Fax: 704-865-6531

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number9500419
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number9500419
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number9500419
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: