Provider Demographics
NPI:1841256526
Name:BOAHENE, DEREK O'KOFI (MD)
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:O'KOFI
Last Name:BOAHENE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:KOFI DEREK
Other - Middle Name:OWUSU
Other - Last Name:BOAHENE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:6201 GREENLEIGH AVE
Mailing Address - Street 2:
Mailing Address - City:MIDDLE RIVER
Mailing Address - State:MD
Mailing Address - Zip Code:21220-2004
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:601 N CAROLINE ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21287-0006
Practice Address - Country:US
Practice Address - Phone:410-955-1686
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-22
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD63373207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD408420900Medicaid
MDKR60JHL1018Medicare PIN
MD408420900Medicaid