Healthcare Provider Details

I. General information

NPI: 1801602842
Provider Name (Legal Business Name): OMRI FORKEH NJOKOM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/04/2024
Last Update Date: 12/04/2024
Certification Date: 12/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11103 ELON CT
BOWIE MD
20720-3505
US

IV. Provider business mailing address

11103 ELON CT
BOWIE MD
20720-3505
US

V. Phone/Fax

Practice location:
  • Phone: 240-906-1581
  • Fax:
Mailing address:
  • Phone: 240-906-1581
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number1447556600
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: