Healthcare Provider Details

I. General information

NPI: 1295987436
Provider Name (Legal Business Name): MAMONLUK CHUA MEDICAL GROUP, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2008
Last Update Date: 01/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1160 VARNUM ST NE SUITE # 008
WASHINGTON DC
20017-2110
US

IV. Provider business mailing address

1160 VARNUM ST NE SUITE # 008
WASHINGTON DC
20017-2110
US

V. Phone/Fax

Practice location:
  • Phone: 202-526-3897
  • Fax: 202-526-7723
Mailing address:
  • Phone: 202-526-3897
  • Fax: 202-526-7723

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License NumberMD037327
License Number StateDC
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD037395
License Number StateDC

VIII. Authorized Official

Name: FERDINAND P CHUA
Title or Position: PRESIDENT
Credential: MD
Phone: 202-526-3897