Provider Demographics
NPI:1316427172
Name:BOFAH, ISAAC O JR
Entity type:Individual
Prefix:
First Name:ISAAC
Middle Name:O
Last Name:BOFAH
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8207 STRATFORD DR
Mailing Address - Street 2:
Mailing Address - City:PARMA
Mailing Address - State:OH
Mailing Address - Zip Code:44129-5509
Mailing Address - Country:US
Mailing Address - Phone:646-784-2740
Mailing Address - Fax:
Practice Address - Street 1:1440 ROCKSIDE RD STE 314
Practice Address - Street 2:
Practice Address - City:PARMA
Practice Address - State:OH
Practice Address - Zip Code:44134-2749
Practice Address - Country:US
Practice Address - Phone:216-220-7557
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-20
Last Update Date:2019-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2018019303363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health