Provider Demographics
NPI:1598895955
Name:MOFU, EMMANUEL R (MD)
Entity Type:Individual
Prefix:
First Name:EMMANUEL
Middle Name:R
Last Name:MOFU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1250
Mailing Address - Street 2:
Mailing Address - City:BLYTHE
Mailing Address - State:CA
Mailing Address - Zip Code:92226-1250
Mailing Address - Country:US
Mailing Address - Phone:760-922-3141
Mailing Address - Fax:760-922-9846
Practice Address - Street 1:495 NORTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:BLYTHE
Practice Address - State:CA
Practice Address - Zip Code:92225
Practice Address - Country:US
Practice Address - Phone:760-922-3141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2009-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC36558207Q00000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOOC365580Medicare ID - Type Unspecified
A36307Medicare UPIN