Provider Demographics
NPI:1386829679
Name:MONYA-TAMBI, INNOCENT (MD)
Entity Type:Individual
Prefix:
First Name:INNOCENT
Middle Name:
Last Name:MONYA-TAMBI
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 1:1709 ROSEMONT AVE
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21702-4135
Mailing Address - Country:US
Mailing Address - Phone:301-624-5999
Mailing Address - Fax:301-624-5997
Practice Address - Street 1:1709 ROSEMONT AVE
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21702-4135
Practice Address - Country:US
Practice Address - Phone:301-624-5999
Practice Address - Fax:301-624-5997
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-04
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDFM4237942207R00000X
VAFM3900518207R00000X
NY265253207R00000X
PAMD448694207R00000X
MDM80945207R00000X
MDD0076463207R00000X
PAFM4310683207R00000X
VA0101254880207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY265253OtherMEDICAL LICENSE
PAMD448694OtherMEDICAL LICENSE
VA0101254880OtherMEDICAL LICENSE
MDM80945OtherCONTROLLED SUBSTANCE LICENSE
VA1386829679Medicaid
TNQ012138Medicaid
MDD0076463OtherMEDICAL LICENSE
TNQ012138Medicaid
MDD0076463OtherMEDICAL LICENSE
PAFM4310683OtherDEA LICENSE
MDM80945OtherCONTROLLED SUBSTANCE LICENSE