Basic Information
| Provider Information | |||||||||
| NPI: | 1841256526 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOAHENE | ||||||||
| FirstName: | DEREK | ||||||||
| MiddleName: | O'KOFI | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BOAHENE | ||||||||
| OtherFirstName: | KOFI DEREK | ||||||||
| OtherMiddleName: | OWUSU | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 64588 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212644588 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105022145 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 601 N CAROLINE ST | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212870006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4109551686 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/22/2006 | ||||||||
| LastUpdateDate: | 02/04/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | D63373 | MD | Y | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 408420900 | 05 | MD | MEDICAID |