Provider Demographics
NPI:1497318182
Name:MBAH, MAXWELL
Entity Type:Individual
Prefix:DR
First Name:MAXWELL
Middle Name:
Last Name:MBAH
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 1:731 SUNNYFIELD LN
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:MD
Mailing Address - Zip Code:21225-3364
Mailing Address - Country:US
Mailing Address - Phone:954-309-4017
Mailing Address - Fax:410-636-6029
Practice Address - Street 1:731 SUNNYFIELD LN
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:MD
Practice Address - Zip Code:21225-3364
Practice Address - Country:US
Practice Address - Phone:954-309-4017
Practice Address - Fax:410-636-6029
Is Sole Proprietor?:No
Enumeration Date:2019-04-17
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLP51025164W00000X
376G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376G00000XNursing Service Related ProvidersNursing Home Administrator
No164W00000XNursing Service ProvidersLicensed Practical Nurse