Provider Demographics
NPI:1790208478
Name:MBAH, VICTOR FUMNYEN
Entity Type:Individual
Prefix:
First Name:VICTOR
Middle Name:FUMNYEN
Last Name:MBAH
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 1:6100 GLENN DALE RD APT 6100
Mailing Address - Street 2:
Mailing Address - City:GLENN DALE
Mailing Address - State:MD
Mailing Address - Zip Code:20769-9211
Mailing Address - Country:US
Mailing Address - Phone:240-486-4917
Mailing Address - Fax:
Practice Address - Street 1:1220 12TH ST SE STE G35
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20003-3738
Practice Address - Country:US
Practice Address - Phone:202-544-8090
Practice Address - Fax:202-544-8091
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-25
Last Update Date:2017-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCHHA12830374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide