Basic Information
| Provider Information | |||||||||
| NPI: | 1114085842 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KANKAM | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | K | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 293 NW PEACOCK BLVD STE 101-104 | ||||||||
| Address2: | |||||||||
| City: | PORT SAINT LUCIE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349862222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7723359600 | ||||||||
| FaxNumber: | 7728794478 | ||||||||
| Practice Location | |||||||||
| Address1: | 293 NW PEACOCK BLVD STE 101-104 | ||||||||
| Address2: | |||||||||
| City: | PORT SAINT LUCIE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349862222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7723359600 | ||||||||
| FaxNumber: | 7728794478 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2006 | ||||||||
| LastUpdateDate: | 10/03/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | OS7965 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 260022600 | 05 | FL | MEDICAID |