Provider Demographics
NPI:1780623074
Name:FORDJOUR, KUSI (MD)
Entity type:Individual
Prefix:DR
First Name:KUSI
Middle Name:
Last Name:FORDJOUR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 93597
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-0115
Mailing Address - Country:US
Mailing Address - Phone:972-283-9100
Mailing Address - Fax:972-283-9104
Practice Address - Street 1:2505 BOLTON BOONE DR
Practice Address - Street 2:STE 101
Practice Address - City:DESOTO
Practice Address - State:TX
Practice Address - Zip Code:75115-2096
Practice Address - Country:US
Practice Address - Phone:972-283-9100
Practice Address - Fax:972-283-9104
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-05
Last Update Date:2012-07-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXL0177207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXL0177OtherSTATE LICENSE
TX0098MTOtherBCBS
TX8B8366Medicare PIN
TX0098MTOtherBCBS