Provider Demographics
NPI:1760187918
Name:DJOMO EPSE KEPSU, IDA DIANE
Entity Type:Individual
Prefix:
First Name:IDA
Middle Name:DIANE
Last Name:DJOMO EPSE KEPSU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1203 DURHAM DR
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20721-3262
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4660 MARTIN LUTHER KING JR AVE SW STE A2
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20032-4933
Practice Address - Country:US
Practice Address - Phone:202-318-0179
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-04
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor