Provider Demographics
NPI:1417446030
Name:NDUM, ROOSEVELT A
Entity Type:Individual
Prefix:
First Name:ROOSEVELT
Middle Name:A
Last Name:NDUM
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 1:14609 PHILIP CT APT 104
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20708-1024
Mailing Address - Country:US
Mailing Address - Phone:240-347-5279
Mailing Address - Fax:
Practice Address - Street 1:1220 12TH ST SE STE G35
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20003-3738
Practice Address - Country:US
Practice Address - Phone:202-544-8090
Practice Address - Fax:202-544-8091
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-09
Last Update Date:2018-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCHHA13654374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide