Provider Demographics
NPI:1790757326
Name:MVEMBA, WILLIE B
Entity Type:Individual
Prefix:DR
First Name:WILLIE
Middle Name:B
Last Name:MVEMBA
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 1:3613 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:WINDSOR MILL
Mailing Address - State:MD
Mailing Address - Zip Code:21244-3776
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:413 COMMONWEALTH AVE
Practice Address - Street 2:SUITE 3
Practice Address - City:CATONSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21228-3044
Practice Address - Country:US
Practice Address - Phone:410-719-0020
Practice Address - Fax:410-744-6755
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-07
Last Update Date:2011-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0055425174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD689RMedicare PIN