Provider Demographics
NPI:1013995851
Name:ABDUL-MBACKE, MAKUNDA (MD)
Entity type:Individual
Prefix:
First Name:MAKUNDA
Middle Name:
Last Name:ABDUL-MBACKE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MAKUNDA
Other - Middle Name:
Other - Last Name:ABDUL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:6890 GREENSBORO RD
Mailing Address - Street 2:
Mailing Address - City:RIDGEWAY
Mailing Address - State:VA
Mailing Address - Zip Code:24148-3555
Mailing Address - Country:US
Mailing Address - Phone:276-956-1013
Mailing Address - Fax:
Practice Address - Street 1:6890 GREENSBORO RD
Practice Address - Street 2:
Practice Address - City:RIDGEWAY
Practice Address - State:VA
Practice Address - Zip Code:24148-3555
Practice Address - Country:US
Practice Address - Phone:276-956-1013
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-03
Last Update Date:2025-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2010-02034207V00000X
VA0101241089207VX0000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8898405Medicaid
058993CO4Medicare ID - Type Unspecified
H64339Medicare UPIN