MEDICARE: MR. JAMES PETERSON MONGO DJOPGANG

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker		MD
2	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1558066084
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JAMES PETERSON MONGO DJOPGANG

Provider Business Mailing Address
First Line	:	13920 CASTLE BLVD APT 606
Second Line	:
City	:	SILVER SPRING
State	:	MD
Zip	:	20904-4959
Country	:	US
Telephone Number	:	301-760-6165
Fax Number	:

Provider Business Practice Location Address
First Line	:	13920 CASTLE BLVD APT 606
Second Line	:
City	:	SILVER SPRING
State	:	MD
Zip	:	20904-4959
Country	:	US
Telephone Number	:	301-760-6165
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/03/2023
Last Update Date	:	10/16/2023

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