Provider Demographics
NPI:1598973778
Name:YAMOAH, JOHNNY GYEBI-ADU (MDFAAP)
Entity Type:Individual
Prefix:
First Name:JOHNNY
Middle Name:GYEBI-ADU
Last Name:YAMOAH
Suffix:
Gender:M
Credentials:MDFAAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2162 SUSSEX DR
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63701-1883
Mailing Address - Country:US
Mailing Address - Phone:417-619-0464
Mailing Address - Fax:
Practice Address - Street 1:1701 LACEY ST
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63701-5230
Practice Address - Country:US
Practice Address - Phone:573-334-4822
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-19
Last Update Date:2013-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009000147207R00000X, 208000000X
IL125050224207R00000X
IL125050244208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO# PENDINGMedicaid
IL036119750Medicaid
IL036119750Medicaid
MO# PENDINGMedicare PIN