Provider Demographics
NPI:1285222141
Name:TAZIFOR, BONJOE
Entity Type:Individual
Prefix:
First Name:BONJOE
Middle Name:
Last Name:TAZIFOR
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 1:36 TINDAL SPRINGS CT
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY VILLAGE
Mailing Address - State:MD
Mailing Address - Zip Code:20886-4908
Mailing Address - Country:US
Mailing Address - Phone:240-474-7633
Mailing Address - Fax:
Practice Address - Street 1:36 TINDAL SPRINGS CT
Practice Address - Street 2:
Practice Address - City:MONTGOMERY VILLAGE
Practice Address - State:MD
Practice Address - Zip Code:20886-4908
Practice Address - Country:US
Practice Address - Phone:240-474-7633
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-06
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC279625494Medicaid