Provider Demographics
NPI:1649007758
Name:FON, DIERUS TEBO
Entity type:Individual
Prefix:MR
First Name:DIERUS
Middle Name:TEBO
Last Name:FON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13303 ARCTIC AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20853-3013
Mailing Address - Country:US
Mailing Address - Phone:240-579-5608
Mailing Address - Fax:
Practice Address - Street 1:13303 ARCTIC AVE
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20853-3013
Practice Address - Country:US
Practice Address - Phone:240-579-5608
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-14
Last Update Date:2025-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator