Provider Demographics
NPI:1467960815
Name:MOFOR, BLAISE NGONGBAN
Entity Type:Individual
Prefix:
First Name:BLAISE
Middle Name:NGONGBAN
Last Name:MOFOR
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 1:76 OLD ENTERPRISE RD
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20774-1648
Mailing Address - Country:US
Mailing Address - Phone:240-817-6297
Mailing Address - Fax:
Practice Address - Street 1:410 WARFIELD DR APT 1094
Practice Address - Street 2:
Practice Address - City:LANDOVER
Practice Address - State:MD
Practice Address - Zip Code:20785-4785
Practice Address - Country:US
Practice Address - Phone:124-081-7629
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-19
Last Update Date:2023-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator