Healthcare Provider Details

I. General information

NPI: 1205187978
Provider Name (Legal Business Name): DESTAING OGU
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2012
Last Update Date: 02/23/2024
Certification Date: 02/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4203 55TH AVE
BLADENSBURG MD
20710-1507
US

IV. Provider business mailing address

4203 55TH AVE
BLADENSBURG MD
20710-1507
US

V. Phone/Fax

Practice location:
  • Phone: 202-545-0935
  • Fax: 202-545-0934
Mailing address:
  • Phone: 202-545-0935
  • Fax: 202-545-0934

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: