Provider Demographics
NPI:1396227203
Name:MBENG NGWEDJANG, ELVIS
Entity Type:Individual
Prefix:MR
First Name:ELVIS
Middle Name:
Last Name:MBENG NGWEDJANG
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 1:5201 QUINCY ST APT B2
Mailing Address - Street 2:
Mailing Address - City:BLADENSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20710-2331
Mailing Address - Country:US
Mailing Address - Phone:240-764-9672
Mailing Address - Fax:
Practice Address - Street 1:5201 QUINCY ST APT B2
Practice Address - Street 2:
Practice Address - City:BLADENSBURG
Practice Address - State:MD
Practice Address - Zip Code:20710-2331
Practice Address - Country:US
Practice Address - Phone:240-764-9672
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-06
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No251S00000XAgenciesCommunity/Behavioral Health
No374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJLIN1890288070OtherWORK PERMIT