Provider Demographics
NPI:1851164651
Name:MBACHAM, EUGENE UFON (MEDICAL PROVIDER)
Entity Type:Individual
Prefix:
First Name:EUGENE
Middle Name:UFON
Last Name:MBACHAM
Suffix:
Gender:M
Credentials:MEDICAL PROVIDER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7810 DOGUE INDIAN CIR
Mailing Address - Street 2:
Mailing Address - City:LORTON
Mailing Address - State:VA
Mailing Address - Zip Code:22079-2145
Mailing Address - Country:US
Mailing Address - Phone:571-494-0355
Mailing Address - Fax:
Practice Address - Street 1:1039 BLADENSBURG RD NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20002-2922
Practice Address - Country:US
Practice Address - Phone:202-507-8139
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-02
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VANA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator