Provider Demographics
NPI:1619316452
Name:BAMENGA, MAXENCE B
Entity Type:Individual
Prefix:MR
First Name:MAXENCE
Middle Name:B
Last Name:BAMENGA
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 1:2538 YATES AVE
Mailing Address - Street 2:PH
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10469
Mailing Address - Country:US
Mailing Address - Phone:718-733-7203
Mailing Address - Fax:
Practice Address - Street 1:2538 YATES AVE
Practice Address - Street 2:PH
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10469-5311
Practice Address - Country:US
Practice Address - Phone:718-733-7203
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-14
Last Update Date:2013-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY556129041174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist