Provider Demographics
NPI:1710375589
Name:ADELA, KOKU
Entity type:Individual
Prefix:
First Name:KOKU
Middle Name:
Last Name:ADELA
Suffix:
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 1:20440 MEADOW POND PLACE
Mailing Address - Street 2:
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20886
Mailing Address - Country:US
Mailing Address - Phone:301-938-3208
Mailing Address - Fax:
Practice Address - Street 1:20440 MEADOW POND PL
Practice Address - Street 2:
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20886-1130
Practice Address - Country:US
Practice Address - Phone:301-938-3208
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-02
Last Update Date:2015-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD8116172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver