1154372274 NPI number — DR. ANTOINE KOFI FOMUFOD M.D.

Table of content: DR. ANTOINE KOFI FOMUFOD M.D. (NPI 1154372274)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154372274 NPI number — DR. ANTOINE KOFI FOMUFOD M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FOMUFOD
Provider First Name:
ANTOINE
Provider Middle Name:
KOFI
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FOMUFOD
Provider Other First Name:
ANTHONY
Provider Other Middle Name:
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1154372274
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/27/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5722 AVERY PARK DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROCKVILLE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20855-1738
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-618-2630
Provider Business Mailing Address Fax Number:
301-618-3941

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3001 HOSPITAL DR
Provider Second Line Business Practice Location Address:
PEDIATRIX MEDICAL GROUP
Provider Business Practice Location Address City Name:
CHEVERLY
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20785-1189
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-618-2630
Provider Business Practice Location Address Fax Number:
301-618-3941
Provider Enumeration Date:
05/13/2006

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: 2080N0001X , with the licence number:  D16239 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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