Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207V00000X | Obstetrician & Gynecologist | 0101241089 | VA |
N | 207VX0000X | Obstetrician | 0101241089 | VA |
NPI | 1013995851 |
---|---|
Provider Name | Makunda Abdul-Mbacke |
First Address | Ridgeway, VA 24148-3555 |
Second Address | Ridgeway, VA 24148-3555 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/01/2006 |
Last Update Date | 20/06/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
8898405 | (05) | NJ |
H64339 | (02) |