Provider Demographics
NPI:1568463529
Name:KANKAM, COLLINS F (MD)
Entity Type:Individual
Prefix:DR
First Name:COLLINS
Middle Name:F
Last Name:KANKAM
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 1:11150 FAIRFAX BLVD
Mailing Address - Street 2:STE 501
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030
Mailing Address - Country:US
Mailing Address - Phone:703-691-2516
Mailing Address - Fax:703-691-3526
Practice Address - Street 1:3300 GALLOWS RD
Practice Address - Street 2:
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22041
Practice Address - Country:US
Practice Address - Phone:703-776-2636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2009-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101040183207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA006600921Medicaid
VA006600921Medicaid
1053311357Medicare PIN
VAE37324Medicare UPIN