Provider Demographics
NPI:1043984792
Name:FONJONG, MARTIN TANWIE (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:TANWIE
Last Name:FONJONG
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11114 POMPEY DR
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20772-4859
Mailing Address - Country:US
Mailing Address - Phone:240-604-6481
Mailing Address - Fax:
Practice Address - Street 1:11114 POMPEY DR
Practice Address - Street 2:
Practice Address - City:UPPER MARLBORO
Practice Address - State:MD
Practice Address - Zip Code:20772-4859
Practice Address - Country:US
Practice Address - Phone:240-604-6481
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-05
Last Update Date:2021-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDF525585785427Medicaid