Provider Demographics
NPI:1093789406
Name:SAM, KWEKU G JR (MD)
Entity Type:Individual
Prefix:DR
First Name:KWEKU
Middle Name:G
Last Name:SAM
Suffix:JR
Gender:M
Credentials:MD
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Mailing Address - Street 1:1625 STRAITS TPKE
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06762-1805
Mailing Address - Country:US
Mailing Address - Phone:203-573-9512
Mailing Address - Fax:203-568-2904
Practice Address - Street 1:1625 STRAITS TPKE
Practice Address - Street 2:
Practice Address - City:MIDDLEBURY
Practice Address - State:CT
Practice Address - Zip Code:06762-1805
Practice Address - Country:US
Practice Address - Phone:203-759-0666
Practice Address - Fax:203-568-2919
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-14
Last Update Date:2007-07-08
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Provider Licenses
StateLicense IDTaxonomies
CT035963208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
G63371Medicare UPIN