Provider Demographics
NPI:1306614581
Name:KODOM, MILTON OPOKU
Entity type:Individual
Prefix:
First Name:MILTON
Middle Name:OPOKU
Last Name:KODOM
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 1:42 MADRID LN
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33324-5545
Mailing Address - Country:US
Mailing Address - Phone:954-508-6467
Mailing Address - Fax:
Practice Address - Street 1:3301 COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33314-7796
Practice Address - Country:US
Practice Address - Phone:954-508-6467
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-18
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPSI45864390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program