Provider Demographics
NPI:1003835000
Name:KETOSUGBO, ANUKWARE (MD)
Entity Type:Individual
Prefix:
First Name:ANUKWARE
Middle Name:
Last Name:KETOSUGBO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5619
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10087-5619
Mailing Address - Country:US
Mailing Address - Phone:718-622-1301
Mailing Address - Fax:718-622-1367
Practice Address - Street 1:20 PLAZA ST E
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11238-4955
Practice Address - Country:US
Practice Address - Phone:718-622-1301
Practice Address - Fax:718-622-1367
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1475452086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01036039Medicaid
NY01036039Medicaid
B80340Medicare UPIN