Provider Demographics
NPI:1265252977
Name:MUBANG, CLINTON ETSHU
Entity type:Individual
Prefix:
First Name:CLINTON
Middle Name:ETSHU
Last Name:MUBANG
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 1:6407 LANDOVER RD
Mailing Address - Street 2:
Mailing Address - City:CHEVERLY
Mailing Address - State:MD
Mailing Address - Zip Code:20785-1405
Mailing Address - Country:US
Mailing Address - Phone:443-599-5971
Mailing Address - Fax:
Practice Address - Street 1:1615 RHODE ISLAND AVE NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20018-1802
Practice Address - Country:US
Practice Address - Phone:202-832-1698
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-16
Last Update Date:2024-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator