Provider Demographics
NPI:1497346480
Name:KUNGANG, DIVINE NDEMAZEH
Entity Type:Individual
Prefix:MR
First Name:DIVINE
Middle Name:NDEMAZEH
Last Name:KUNGANG
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 1:6505 MANTON WAY
Mailing Address - Street 2:
Mailing Address - City:LANHAM
Mailing Address - State:MD
Mailing Address - Zip Code:20706-2488
Mailing Address - Country:US
Mailing Address - Phone:240-906-4174
Mailing Address - Fax:
Practice Address - Street 1:4130 HUNT PL NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20019-3565
Practice Address - Country:US
Practice Address - Phone:202-388-4300
Practice Address - Fax:202-388-4339
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-01
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
68272081OtherKAISER
MD68272081OtherKAISER
MD68272081Medicaid