Provider Demographics
NPI:1407430457
Name:ODURO-BOADU, KOFI (MD)
Entity Type:Individual
Prefix:DR
First Name:KOFI
Middle Name:
Last Name:ODURO-BOADU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:KOFI
Other - Middle Name:
Other - Last Name:ODURO-BOADU
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:2500 NORTH STATE STREET
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-984-5426
Mailing Address - Fax:601-984-6889
Practice Address - Street 1:2500 NORTH STATE STREET
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-984-5426
Practice Address - Fax:601-984-6889
Is Sole Proprietor?:No
Enumeration Date:2021-05-06
Last Update Date:2022-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MST-4311207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program