Healthcare Provider Details

I. General information

NPI: 1033757976
Provider Name (Legal Business Name): KOUAKOU ANSUMANE BOUDJIHO-BEY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/10/2019
Last Update Date: 12/10/2019
Certification Date: 12/10/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1108 WARFIELD DR
PORTSMOUTH VA
23701-3831
US

IV. Provider business mailing address

1108 WARFIELD DR
PORTSMOUTH VA
23701-3831
US

V. Phone/Fax

Practice location:
  • Phone: 757-971-8142
  • Fax:
Mailing address:
  • Phone: 757-971-8142
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License NumberT60545514
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: