Healthcare Provider Details

I. General information

NPI: 1457629941
Provider Name (Legal Business Name): ANUKWARE KETOSUGBO, MD, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2011
Last Update Date: 07/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 PLAZA STEET EAST
BROOKLYN NY
11238
US

IV. Provider business mailing address

PO BOX 5619
NEW YORK NY
10087-5619
US

V. Phone/Fax

Practice location:
  • Phone: 718-622-1301
  • Fax: 718-622-1367
Mailing address:
  • Phone: 718-622-1301
  • Fax: 718-622-1367

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number147545
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number147545
License Number StateNY

VIII. Authorized Official

Name: ANUKWARE K KETOSUGBO
Title or Position: OWNER
Credential: MD
Phone: 718-622-1301