Healthcare Provider Details

I. General information

NPI: 1144752106
Provider Name (Legal Business Name): MFONISO D UMOREN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2017
Last Update Date: 09/29/2025
Certification Date: 09/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

804 LANDMARK DR STE 118
GLEN BURNIE MD
21061-4486
US

IV. Provider business mailing address

804 LANDMARK DR STE 118
GLEN BURNIE MD
21061-4486
US

V. Phone/Fax

Practice location:
  • Phone: 410-863-4899
  • Fax:
Mailing address:
  • Phone: 410-863-4899
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number71523
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD048197
License Number StateDC
# 3
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberD0098776
License Number StateMD
# 4
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number71523
License Number StateTN
# 5
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberMD048197
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: