Provider Demographics
NPI: | 1922155563 |
---|---|
Name: | FOFUNG, SEMA JUSTUS (DO) |
Entity Type: | Individual |
Prefix: | MR |
First Name: | SEMA |
Middle Name: | JUSTUS |
Last Name: | FOFUNG |
Suffix: | |
Gender: | M |
Credentials: | DO |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 735 SOUTH SHOOP AVENUE |
Mailing Address - Street 2: | SUITE 3 |
Mailing Address - City: | WAUSEON |
Mailing Address - State: | OH |
Mailing Address - Zip Code: | 43567 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 419-335-6377 |
Mailing Address - Fax: | 419-335-6807 |
Practice Address - Street 1: | 735 SOUTH SHOOP AVENUE |
Practice Address - Street 2: | SUITE 3 |
Practice Address - City: | WAUSEON |
Practice Address - State: | OH |
Practice Address - Zip Code: | 43567 |
Practice Address - Country: | US |
Practice Address - Phone: | 419-335-6377 |
Practice Address - Fax: | 419-335-6807 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2007-01-05 |
Last Update Date: | 2023-02-09 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
OH | 34007671 | 174400000X |
OH | 34.007671 | 207V00000X |
OH | 34-007671 | 174400000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 174400000X | Other Service Providers | Specialist | |
No | 207V00000X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
OH | 2317479 | Medicaid | |
OH | H27109 | Medicare UPIN | |
OH | 4085682 | Medicare PIN |