Provider Demographics
NPI:1821566241
Name:DIATSA, FOPPA PATRICK CLAVEL
Entity Type:Individual
Prefix:
First Name:FOPPA PATRICK
Middle Name:CLAVEL
Last Name:DIATSA
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 1:2759 MARTIN LUTHER KING JR AVE SE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20032-2646
Mailing Address - Country:US
Mailing Address - Phone:202-827-9961
Mailing Address - Fax:
Practice Address - Street 1:2759 MARTIN LUTHER KING JR AVE SE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20032-2646
Practice Address - Country:US
Practice Address - Phone:240-640-1674
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-02
Last Update Date:2023-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC251E00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No251E00000XAgenciesHome Health