Basic Information
| Provider Information | |||||||||
| NPI: | 1093246613 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SAMPONG | ||||||||
| FirstName: | EBENEZER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12027 PARC AUX CHENES | ||||||||
| Address2: | |||||||||
| City: | GULFPORT | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395034570 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9186712813 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5001 HARDY ST | ||||||||
| Address2: | |||||||||
| City: | HATTIESBURG | ||||||||
| State: | MS | ||||||||
| PostalCode: | 39402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012963963 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2017 | ||||||||
| LastUpdateDate: | 06/22/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.