Provider Demographics
NPI:1164521019
Name:JACK, MOMODU A (MD)
Entity Type:Individual
Prefix:
First Name:MOMODU
Middle Name:A
Last Name:JACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2325
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21045-1325
Mailing Address - Country:US
Mailing Address - Phone:202-865-7981
Mailing Address - Fax:301-621-5313
Practice Address - Street 1:2139 GEORGIA AVE NW
Practice Address - Street 2:SUITE 3A
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20001-3035
Practice Address - Country:US
Practice Address - Phone:202-865-7981
Practice Address - Fax:301-621-5313
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2020-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0044035207RG0100X
VA0101270422207RG0100X
DCMD20286207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0101267872OtherLICENSE
MD174961700Medicaid
DC018868500Medicaid
DC018868500Medicaid