Healthcare Provider Details

I. General information

NPI: 1811439797
Provider Name (Legal Business Name): WONDWOSSEN MEKBIB PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2016
Last Update Date: 03/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2830 CAMPUS WAY N STE 616
LANHAM MD
20706-1669
US

IV. Provider business mailing address

350 NEW FIDELITY CT
GARNER NC
27529-2665
US

V. Phone/Fax

Practice location:
  • Phone: 301-798-7014
  • Fax: 301-720-0126
Mailing address:
  • Phone: 919-535-8758
  • Fax: 919-535-3271

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number26814
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: