Provider Demographics
NPI:1134824238
Name:FONGANG, KWEKAM DIDI PARFAIT
Entity type:Individual
Prefix:
First Name:KWEKAM
Middle Name:DIDI PARFAIT
Last Name:FONGANG
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 1:5914 85TH AVE
Mailing Address - Street 2:
Mailing Address - City:NEW CARROLLTON
Mailing Address - State:MD
Mailing Address - Zip Code:20784-2802
Mailing Address - Country:US
Mailing Address - Phone:240-584-3902
Mailing Address - Fax:
Practice Address - Street 1:2811 PENNSYLVANIA AVE SE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20020-3865
Practice Address - Country:US
Practice Address - Phone:202-597-1146
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-30
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty