Provider Demographics
NPI:1467851634
Name:ETOKAKPAN, MBOUTIDEM (MD)
Entity Type:Individual
Prefix:
First Name:MBOUTIDEM
Middle Name:
Last Name:ETOKAKPAN
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 1:2100 MACK BLVD FL 4
Mailing Address - Street 2:
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18103-5622
Mailing Address - Country:US
Mailing Address - Phone:570-501-6368
Mailing Address - Fax:570-501-4754
Practice Address - Street 1:50 MOISEY DR
Practice Address - Street 2:
Practice Address - City:HAZLE TOWNSHIP
Practice Address - State:PA
Practice Address - Zip Code:18202-9297
Practice Address - Country:US
Practice Address - Phone:570-501-6900
Practice Address - Fax:570-501-6945
Is Sole Proprietor?:No
Enumeration Date:2014-08-14
Last Update Date:2022-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.138339208600000X
PAMD469829208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery