Provider Demographics
NPI:1649724394
Name:KOKU, RUTH (MD)
Entity type:Individual
Prefix:
First Name:RUTH
Middle Name:
Last Name:KOKU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:634 WALDEN LANDING DR
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:GA
Mailing Address - Zip Code:30228-6234
Mailing Address - Country:US
Mailing Address - Phone:954-821-7494
Mailing Address - Fax:770-471-4468
Practice Address - Street 1:634 WALDEN LANDING DR
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:GA
Practice Address - Zip Code:30228-6234
Practice Address - Country:US
Practice Address - Phone:954-821-7494
Practice Address - Fax:770-471-4468
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-11
Last Update Date:2016-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2597822163W00000X
GA196779163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL302750300Medicaid