Provider Demographics
NPI:1114085842
Name:KANKAM, EDWARD K (DO)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:K
Last Name:KANKAM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:293 NW PEACOCK BLVD STE 101-104
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34986-2222
Mailing Address - Country:US
Mailing Address - Phone:772-335-9600
Mailing Address - Fax:772-879-4478
Practice Address - Street 1:293 NW PEACOCK BLVD STE 101-104
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34986-2222
Practice Address - Country:US
Practice Address - Phone:772-335-9600
Practice Address - Fax:772-879-4478
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2019-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS7965207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL260022600Medicaid
FLH23732Medicare UPIN
FL49526ZMedicare ID - Type Unspecified