Provider Demographics
NPI:1033757976
Name:BOUDJIHO-BEY, KOUAKOU ANSUMANE
Entity Type:Individual
Prefix:
First Name:KOUAKOU
Middle Name:ANSUMANE
Last Name:BOUDJIHO-BEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1108 WARFIELD DR
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23701-3831
Mailing Address - Country:US
Mailing Address - Phone:757-971-8142
Mailing Address - Fax:
Practice Address - Street 1:1108 WARFIELD DR
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23701-3831
Practice Address - Country:US
Practice Address - Phone:757-971-8142
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-10
Last Update Date:2019-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAT60545514172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172A00000XOther Service ProvidersDriverGroup - Single Specialty