Provider Demographics
NPI:1679689194
Name:EWUSI-MENSAH, THEODORA (MD)
Entity Type:Individual
Prefix:
First Name:THEODORA
Middle Name:
Last Name:EWUSI-MENSAH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:THEODORA
Other - Middle Name:ABAKA
Other - Last Name:ACQUAAH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MBCHB
Mailing Address - Street 1:14 FRANCISCAN PLACE
Mailing Address - Street 2:
Mailing Address - City:PHILLIPS RANCH
Mailing Address - State:CA
Mailing Address - Zip Code:91766-4867
Mailing Address - Country:US
Mailing Address - Phone:909-983-4746
Mailing Address - Fax:
Practice Address - Street 1:304 WEST F STREET
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91762-3206
Practice Address - Country:US
Practice Address - Phone:909-983-4746
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA31536208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A315360Medicaid