Healthcare Provider Details

I. General information

NPI: 1144553553
Provider Name (Legal Business Name): MOMPOLOKI BENSON KEALEBOGA NKHUMANE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2009
Last Update Date: 05/05/2023
Certification Date: 05/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 W GRAND AVE
DAYTON OH
45405
US

IV. Provider business mailing address

1 PRESTIGE PL STE 550
MIAMISBURG OH
45342-6115
US

V. Phone/Fax

Practice location:
  • Phone: 937-395-6665
  • Fax: 937-395-6668
Mailing address:
  • Phone: 937-762-1300
  • Fax: 937-542-8493

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number9071A
License Number StateWY
# 2
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number35.132685
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number9071A
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: