Provider Demographics
NPI:1659563146
Name:KWABENA AYESU M D P A
Entity Type:Organization
Organization Name:KWABENA AYESU M D P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KWABENA
Authorized Official - Middle Name:
Authorized Official - Last Name:AYESU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:386-774-6111
Mailing Address - Street 1:86 SPRING VISTA DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:DEBARY
Mailing Address - State:FL
Mailing Address - Zip Code:32713-1818
Mailing Address - Country:US
Mailing Address - Phone:386-774-6111
Mailing Address - Fax:386-774-8111
Practice Address - Street 1:86 SPRING VISTA DR
Practice Address - Street 2:SUITE 100
Practice Address - City:DEBARY
Practice Address - State:FL
Practice Address - Zip Code:32713-1818
Practice Address - Country:US
Practice Address - Phone:386-774-6111
Practice Address - Fax:386-774-8111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-17
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL81108BOtherBCBS
FLP00269607OtherRAILROAD MEDICARE
FLK8212Medicare PIN