Provider Demographics
NPI:1760232250
Name:KOUOKAM SIPOWA, ROSTAN
Entity Type:Individual
Prefix:
First Name:ROSTAN
Middle Name:
Last Name:KOUOKAM SIPOWA
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 1:802 TILGHMAN DR
Mailing Address - Street 2:
Mailing Address - City:DUNN
Mailing Address - State:NC
Mailing Address - Zip Code:28334-5510
Mailing Address - Country:US
Mailing Address - Phone:910-766-7711
Mailing Address - Fax:
Practice Address - Street 1:802 TILGHMAN DR
Practice Address - Street 2:
Practice Address - City:DUNN
Practice Address - State:NC
Practice Address - Zip Code:28334-5510
Practice Address - Country:US
Practice Address - Phone:910-766-7711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-26
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD10274584378207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine