Healthcare Provider Details

I. General information

NPI: 1477894764
Provider Name (Legal Business Name): KOUAME STEPHANE NDRI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: STEPHANE KOUAME NDRI MD

II. Dates (important events)

Enumeration Date: 03/11/2013
Last Update Date: 07/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

779 GRAPEVINE HWY
HURST TX
76054-2805
US

IV. Provider business mailing address

PO BOX 9101
COPPELL TX
75019-9494
US

V. Phone/Fax

Practice location:
  • Phone: 817-428-7300
  • Fax: 817-428-1085
Mailing address:
  • Phone: 972-745-7500
  • Fax: 972-471-0700

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberBP10047109
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberQ7435
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: