Provider Demographics
NPI:1649520529
Name:MBAH, STEPHEN M
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:M
Last Name:MBAH
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 1:1822 METZEROTT RD APT 407
Mailing Address - Street 2:
Mailing Address - City:ADELPHI
Mailing Address - State:MD
Mailing Address - Zip Code:20783-5162
Mailing Address - Country:US
Mailing Address - Phone:240-581-2620
Mailing Address - Fax:
Practice Address - Street 1:1822 METZEROTT RD APT 407
Practice Address - Street 2:
Practice Address - City:ADELPHI
Practice Address - State:MD
Practice Address - Zip Code:20783-5162
Practice Address - Country:US
Practice Address - Phone:240-581-2620
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-18
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
374U00000X
DCLPN1005610164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC036061400Medicaid