Provider Demographics
NPI:1245690304
Name:EFEUTFACK, MARTIN
Entity type:Individual
Prefix:
First Name:MARTIN
Middle Name:
Last Name:EFEUTFACK
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 1:2104 COLUMBIA AVE
Mailing Address - Street 2:
Mailing Address - City:HYATTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20785-4948
Mailing Address - Country:US
Mailing Address - Phone:571-510-1024
Mailing Address - Fax:
Practice Address - Street 1:2104 COLUMBIA AVE
Practice Address - Street 2:
Practice Address - City:HYATTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20785-4948
Practice Address - Country:US
Practice Address - Phone:571-510-1024
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-02
Last Update Date:2016-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCHHA11885374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide