1457055733 NPI number — JOHN-STEPHANE SHOUMOU KOUAM MD

Table of content: JOHN-STEPHANE SHOUMOU KOUAM MD (NPI 1457055733)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457055733 NPI number — JOHN-STEPHANE SHOUMOU KOUAM MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KOUAM
Provider First Name:
JOHN-STEPHANE
Provider Middle Name:
SHOUMOU
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1457055733
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/29/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
442 BRISTOL ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROANOKE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76262-6415
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
682-554-1974
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6363 FOREST PARK RD FL 27
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75235-5479
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-648-7312
Provider Business Practice Location Address Fax Number:
214-648-7370
Provider Enumeration Date:
03/29/2023

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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