Provider Demographics
NPI:1760620975
Name:NGOMBA, JASPER IMBOEMBOE (MD)
Entity Type:Individual
Prefix:DR
First Name:JASPER
Middle Name:IMBOEMBOE
Last Name:NGOMBA
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 1:380 ELM ST STE 1
Mailing Address - Street 2:
Mailing Address - City:NORTH ATTLEBORO
Mailing Address - State:MA
Mailing Address - Zip Code:02760-3314
Mailing Address - Country:US
Mailing Address - Phone:774-643-6261
Mailing Address - Fax:
Practice Address - Street 1:380 ELM ST STE 1
Practice Address - Street 2:
Practice Address - City:NORTH ATTLEBORO
Practice Address - State:MA
Practice Address - Zip Code:02760-3314
Practice Address - Country:US
Practice Address - Phone:774-643-6261
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-26
Last Update Date:2020-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD13372207R00000X
MA245843207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110093437AMedicaid
MAS400311281Medicare PIN
MA110093437AMedicaid
MA001738403Medicare PIN
MAS400121420Medicare PIN