Provider Demographics
NPI:1679271670
Name:AGYEKUM, AUGUSTINE KWAKU
Entity Type:Individual
Prefix:DR
First Name:AUGUSTINE
Middle Name:KWAKU
Last Name:AGYEKUM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:932 7TH ST APT 4
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90403-2735
Mailing Address - Country:US
Mailing Address - Phone:215-779-0805
Mailing Address - Fax:
Practice Address - Street 1:1815 BLACKBERRY LN
Practice Address - Street 2:
Practice Address - City:GLADWYNE
Practice Address - State:PA
Practice Address - Zip Code:19035-1101
Practice Address - Country:US
Practice Address - Phone:877-225-0316
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-20
Last Update Date:2023-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service