Provider Demographics
NPI:1881749166
Name:MBUALUNGU, EMMANUEL TED (MD)
Entity type:Individual
Prefix:
First Name:EMMANUEL
Middle Name:TED
Last Name:MBUALUNGU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14600 CEDAR KNOLL DR
Mailing Address - Street 2:
Mailing Address - City:CENTREVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20120-2895
Mailing Address - Country:US
Mailing Address - Phone:703-968-2855
Mailing Address - Fax:
Practice Address - Street 1:106 IRVING ST NW
Practice Address - Street 2:SUITE 403
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20010-2989
Practice Address - Country:US
Practice Address - Phone:202-291-1645
Practice Address - Fax:202-291-1062
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2012-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC21791207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC22932100Medicaid
DCG55432Medicare UPIN
DCG01481Medicare ID - Type Unspecified