Healthcare Provider Details

I. General information

NPI: 1194911263
Provider Name (Legal Business Name): MR. EVANS SUELLER MASYONGO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2007
Last Update Date: 09/21/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

751 TWINBROOK PKWY 1ST. FLOOR
ROCKVILLE MD
20851-1400
US

IV. Provider business mailing address

751 TWINBROOK PKWY 1ST. FLOOR
ROCKVILLE MD
20851-1400
US

V. Phone/Fax

Practice location:
  • Phone: 301-838-4100
  • Fax:
Mailing address:
  • Phone: 301-838-4100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: