Healthcare Provider Details

I. General information

NPI: 1386562791
Provider Name (Legal Business Name): MASANGO MOFA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2026
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4660 MARTIN LUTHER KING JR AVE SW
WASHINGTON DC
20032-4933
US

IV. Provider business mailing address

13608 HEBRON LN
UPPER MARLBORO MD
20774-8469
US

V. Phone/Fax

Practice location:
  • Phone: 202-851-6933
  • Fax:
Mailing address:
  • Phone: 202-989-5369
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: