Provider Demographics
NPI:1679283642
Name:FORKUM, MICAH
Entity Type:Individual
Prefix:
First Name:MICAH
Middle Name:
Last Name:FORKUM
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 1:9741 GOOD LUCK RD APT 10
Mailing Address - Street 2:
Mailing Address - City:LANHAM
Mailing Address - State:MD
Mailing Address - Zip Code:20706-3320
Mailing Address - Country:US
Mailing Address - Phone:774-204-2665
Mailing Address - Fax:
Practice Address - Street 1:9741 GOOD LUCK RD APT 10
Practice Address - Street 2:
Practice Address - City:LANHAM
Practice Address - State:MD
Practice Address - Zip Code:20706-3320
Practice Address - Country:US
Practice Address - Phone:774-204-2665
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-01
Last Update Date:2022-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator