Provider Demographics
NPI:1780029140
Name:FONGOD, DEGHA (MD)
Entity Type:Individual
Prefix:
First Name:DEGHA
Middle Name:
Last Name:FONGOD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44121 HARRY BYRD HWY STE 145
Mailing Address - Street 2:
Mailing Address - City:ASHBURN
Mailing Address - State:VA
Mailing Address - Zip Code:20147-5667
Mailing Address - Country:US
Mailing Address - Phone:703-879-4729
Mailing Address - Fax:
Practice Address - Street 1:44121 HARRY BYRD HWY STE 145
Practice Address - Street 2:
Practice Address - City:ASHBURN
Practice Address - State:VA
Practice Address - Zip Code:20147-5667
Practice Address - Country:US
Practice Address - Phone:703-879-4729
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-29
Last Update Date:2020-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101263117207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA531052YJC4Medicare PIN