Provider Demographics
NPI:1780818500
Name:NGUM, EMELDA C (OTR)
Entity Type:Individual
Prefix:
First Name:EMELDA
Middle Name:C
Last Name:NGUM
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3895 MACK RD
Mailing Address - Street 2:#110
Mailing Address - City:FAIRFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45014-7655
Mailing Address - Country:US
Mailing Address - Phone:513-942-0227
Mailing Address - Fax:
Practice Address - Street 1:1390 KING TREE DR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45405-1401
Practice Address - Country:US
Practice Address - Phone:540-793-1845
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-07
Last Update Date:2009-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOT . 006484171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHMEDICAREMedicaid