Provider Demographics
NPI:1457335242
Name:BRUCE MENSAH, KOFI (MD)
Entity Type:Individual
Prefix:
First Name:KOFI
Middle Name:
Last Name:BRUCE MENSAH
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 1:851 DURHAM ROAD
Mailing Address - Street 2:SUITE D
Mailing Address - City:WAKE FOREST
Mailing Address - State:NC
Mailing Address - Zip Code:27587-8793
Mailing Address - Country:US
Mailing Address - Phone:919-554-0900
Mailing Address - Fax:336-784-1116
Practice Address - Street 1:851 DURHAM ROAD
Practice Address - Street 2:SUITE D
Practice Address - City:WAKE FOREST
Practice Address - State:NC
Practice Address - Zip Code:27587-8793
Practice Address - Country:US
Practice Address - Phone:919-554-0900
Practice Address - Fax:336-784-1116
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-05
Last Update Date:2014-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC01429207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00247762OtherRR MEDICARE IND
2333540OtherMEDICARE GROUP
DD7390OtherRR GROUP
NC891301PMedicaid
P00247762OtherRR MEDICARE IND
G07924Medicare UPIN