Provider Demographics
NPI:1083641534
Name:KWAKU, MAXWELL PROSPER (MD)
Entity Type:Individual
Prefix:
First Name:MAXWELL
Middle Name:PROSPER
Last Name:KWAKU
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 9477
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75711-9477
Mailing Address - Country:US
Mailing Address - Phone:903-594-2450
Mailing Address - Fax:903-509-0943
Practice Address - Street 1:1000 5TH STREET
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701
Practice Address - Country:US
Practice Address - Phone:903-590-5190
Practice Address - Fax:903-590-5199
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2018-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM1861207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00229235OtherMEDICARE RR
TX8G6046Medicare PIN
P00229235OtherMEDICARE RR
P00229235Medicare PIN