Provider Demographics
NPI:1639215312
Name:BOATENG, KWABENA A (MD)
Entity Type:Individual
Prefix:
First Name:KWABENA
Middle Name:A
Last Name:BOATENG
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 1:2214 N UNIVERSITY ST
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61604-3221
Mailing Address - Country:US
Mailing Address - Phone:309-680-7669
Mailing Address - Fax:309-681-8443
Practice Address - Street 1:2321 N WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61603-5613
Practice Address - Country:US
Practice Address - Phone:309-680-7600
Practice Address - Fax:309-681-4681
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036084514207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036084514Medicaid
F32971Medicare UPIN