Provider Demographics
NPI:1114798113
Name:FONGOH, BENARD DOH
Entity Type:Individual
Prefix:
First Name:BENARD
Middle Name:DOH
Last Name:FONGOH
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 1:2326 VIRGINIA AVE APT 203
Mailing Address - Street 2:
Mailing Address - City:HYATTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20785-3348
Mailing Address - Country:US
Mailing Address - Phone:301-851-1047
Mailing Address - Fax:
Practice Address - Street 1:2326 VIRGINIA AVE APT 203
Practice Address - Street 2:
Practice Address - City:HYATTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20785-3348
Practice Address - Country:US
Practice Address - Phone:301-851-1047
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-10
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide