Provider Demographics
NPI:1417652256
Name:FONGOH, JUSTIN DODGIMA (FJ)
Entity Type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:DODGIMA
Last Name:FONGOH
Suffix:
Gender:M
Credentials:FJ
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7727 RIVERDALE RD APT 202
Mailing Address - Street 2:
Mailing Address - City:NEW CARROLLTON
Mailing Address - State:MD
Mailing Address - Zip Code:20784-3953
Mailing Address - Country:US
Mailing Address - Phone:301-675-9569
Mailing Address - Fax:
Practice Address - Street 1:7727 RIVERDALE RD APT 202
Practice Address - Street 2:
Practice Address - City:NEW CARROLLTON
Practice Address - State:MD
Practice Address - Zip Code:20784-3953
Practice Address - Country:US
Practice Address - Phone:301-675-9569
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-03
Last Update Date:2023-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172V00000XOther Service ProvidersCommunity Health Worker