Basic Information
| Provider Information | |||||||||
| NPI: | 1225019284 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AYESU | ||||||||
| FirstName: | KWABENA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 21 W COLUMBIA ST | ||||||||
| Address2: | MP 160 | ||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328061133 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3218416600 | ||||||||
| FaxNumber: | 3218414085 | ||||||||
| Practice Location | |||||||||
| Address1: | 21 W COLUMBIA ST | ||||||||
| Address2: | MP 160 | ||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328061133 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3218416600 | ||||||||
| FaxNumber: | 3218414085 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2005 | ||||||||
| LastUpdateDate: | 11/10/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | ME87178 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 562500290 | 01 | FL | TAX ID # | OTHER | P00269607 | 01 | FL | RAILROAD MEDICARE | OTHER | 81108B | 01 | FL | BCBS | OTHER | ME87178 | 01 | FL | MEDICAL LICENSE | OTHER | 268001700 | 05 | FL | MEDICAID | 4557320 | 01 | FL | CIGNA | OTHER |