Provider Demographics
NPI:1790547396
Name:ACHA, GORDON MOFOR
Entity Type:Individual
Prefix:
First Name:GORDON
Middle Name:MOFOR
Last Name:ACHA
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 1:4509 DOCTOR BEANS LEGACY CIR
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20720-6385
Mailing Address - Country:US
Mailing Address - Phone:240-486-1941
Mailing Address - Fax:
Practice Address - Street 1:4660 MARTIN LUTHER KING JR AVE SW
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:2024-01-29
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator