Provider Demographics
NPI:1700809894
Name:MPOY KANYINDA, JEAN-MARIE KAKUBUDIA (MD)
Entity Type:Individual
Prefix:
First Name:JEAN-MARIE
Middle Name:KAKUBUDIA
Last Name:MPOY KANYINDA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:KANYINDA
Other - Middle Name:KAKUBUDIA
Other - Last Name:MPOY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:7401 GRANBY ST
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23505-3406
Mailing Address - Country:US
Mailing Address - Phone:757-388-9925
Mailing Address - Fax:757-793-4145
Practice Address - Street 1:7401 GRANBY ST
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23505-3406
Practice Address - Country:US
Practice Address - Phone:757-388-9925
Practice Address - Fax:757-793-4145
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2013-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM95307207R00000X
VA0101254723207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMF3629Medicaid
NMF3629Medicaid