Provider Demographics
NPI:1629721667
Name:EBUNJI, BERTRAND NKAFU ANDUKWA (MD)
Entity Type:Individual
Prefix:DR
First Name:BERTRAND
Middle Name:NKAFU ANDUKWA
Last Name:EBUNJI
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 1:47149 BUSE RD BLDG 1370
Mailing Address - Street 2:
Mailing Address - City:PATUXENT RIVER
Mailing Address - State:MD
Mailing Address - Zip Code:20670-1540
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:47149 BUSE RD BLDG 1370
Practice Address - Street 2:
Practice Address - City:PATUXENT RIVER
Practice Address - State:MD
Practice Address - Zip Code:20670-1540
Practice Address - Country:US
Practice Address - Phone:301-342-0029
Practice Address - Fax:301-342-4054
Is Sole Proprietor?:No
Enumeration Date:2022-01-31
Last Update Date:2024-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101279747208D00000X
171000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No171000000XOther Service ProvidersMilitary Health Care Provider