Provider Demographics
NPI:1659049138
Name:THADDEUS FON, MOKOM
Entity type:Individual
Prefix:
First Name:MOKOM
Middle Name:
Last Name:THADDEUS 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 1:10010 MARTIN AVE
Mailing Address - Street 2:
Mailing Address - City:GLENN DALE
Mailing Address - State:MD
Mailing Address - Zip Code:20769-9209
Mailing Address - Country:US
Mailing Address - Phone:202-400-7531
Mailing Address - Fax:
Practice Address - Street 1:10010 MARTIN AVE
Practice Address - Street 2:
Practice Address - City:GLENN DALE
Practice Address - State:MD
Practice Address - Zip Code:20769-9209
Practice Address - Country:US
Practice Address - Phone:508-271-5274
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-31
Last Update Date:2025-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide