Healthcare Provider Details

I. General information

NPI: 1053007526
Provider Name (Legal Business Name): GYASI KODUA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2023
Last Update Date: 09/11/2026
Certification Date: 09/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7980 STATE ROUTE 12
BARNEVELD NY
13304-2540
US

IV. Provider business mailing address

111 HOSPITAL DR ATTN:CREDENTIALING
UTICA NY
13502-2517
US

V. Phone/Fax

Practice location:
  • Phone: 315-624-8440
  • Fax: 315-624-8842
Mailing address:
  • Phone: 315-624-6101
  • Fax: 315-624-6744

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number345996
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: