Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208000000X | Pediatrician | A77940 | CA |
NPI | 1003898792 |
---|---|
Provider Name | Dr. Kofi Adade-Boafo |
First Address | San Bernardino, CA 92423-2209 |
Second Address | San Bernardino, CA 92404-4811 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/11/2005 |
Last Update Date | 23/10/2015 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
A77940 | MD LICENSE (01) | CA |