Provider Demographics
NPI:1811101348
Name:KUSI FORDJOUR M.D PA
Entity type:Organization
Organization Name:KUSI FORDJOUR M.D PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:
Authorized Official - First Name:KUSI
Authorized Official - Middle Name:
Authorized Official - Last Name:FORDJOUR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:214-673-3934
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:972-264-9100
Mailing Address - Fax:972-283-9104
Practice Address - Street 1:2505 BOLTON BOONE DR
Practice Address - Street 2:#101
Practice Address - City:DESOTO
Practice Address - State:TX
Practice Address - Zip Code:75115-2013
Practice Address - Country:US
Practice Address - Phone:972-264-9100
Practice Address - Fax:972-283-9104
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-10
Last Update Date:2011-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL0177207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0098MTOtherBCBS
TX173380001Medicaid
TXL0177OtherLICENCE
TX=========OtherEIN
TX00647WMedicare ID - Type UnspecifiedMEDICRAE IND NUMBER
TX=========OtherEIN
TX173380001Medicaid