Provider Demographics
NPI:1902460942
Name:SIMANGO-YIADOM, MPEPERA
Entity Type:Individual
Prefix:
First Name:MPEPERA
Middle Name:
Last Name:SIMANGO-YIADOM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1304 CEDARCROFT RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21239-2001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:101 NICOLLS RD DEPT OF
Practice Address - Street 2:
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794-0001
Practice Address - Country:US
Practice Address - Phone:631-444-2037
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-25
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY390200000X
MD01730213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program