Provider Demographics
NPI:1568859437
Name:NYAKABAU, MUTSA
Entity Type:Individual
Prefix:
First Name:MUTSA
Middle Name:
Last Name:NYAKABAU
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 1:1502 HEATHER HOLLOW CIR
Mailing Address - Street 2:APT. 34
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20904-2373
Mailing Address - Country:US
Mailing Address - Phone:703-869-2785
Mailing Address - Fax:
Practice Address - Street 1:201 S CLEVELAND AVE
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21740-5745
Practice Address - Country:US
Practice Address - Phone:301-745-3777
Practice Address - Fax:301-393-3459
Is Sole Proprietor?:No
Enumeration Date:2015-04-18
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD00851192080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine