Provider Demographics
NPI:1992750186
Name:AMEXO, KWAKU (MD)
Entity type:Individual
Prefix:
First Name:KWAKU
Middle Name:
Last Name:AMEXO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 WASHINGTON AVE
Mailing Address - Street 2:UNIT 710
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19147-3839
Mailing Address - Country:US
Mailing Address - Phone:609-506-5543
Mailing Address - Fax:
Practice Address - Street 1:1101 WASHINGTON AVE
Practice Address - Street 2:UNIT 710
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19147-3839
Practice Address - Country:US
Practice Address - Phone:609-506-5543
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2013-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD056047207R00000X
PAMD056047L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAP00766575OtherRR MEDICARE
PA0198383000OtherKEYSTONE HEALTH PLAN EAST
PA001584998Medicaid
PA001584998 0008Medicaid
PA0198383000OtherIBX
PA0198383000OtherKEYSTONE HEALTH PLAN EAST
PA001584998 0008Medicaid
PA474293ZCHMMedicare PIN
PA474293Medicare PIN