Provider Demographics
NPI:1700131430
Name:MUKABI, MICHAEL GREGORY
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:GREGORY
Last Name:MUKABI
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 1:790 FAIRVIEW AVE APT 315
Mailing Address - Street 2:
Mailing Address - City:TAKOMA PARK
Mailing Address - State:MD
Mailing Address - Zip Code:20912-5957
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7410 GEORGE AVE
Practice Address - Street 2:
Practice Address - City:NORTH WEST
Practice Address - State:DC
Practice Address - Zip Code:20012
Practice Address - Country:US
Practice Address - Phone:202-558-7747
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-18
Last Update Date:2012-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD62407251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health