Healthcare Provider Details

I. General information

NPI: 1013995851
Provider Name (Legal Business Name): MAKUNDA ABDUL-MBACKE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MAKUNDA ABDUL MD

II. Dates (important events)

Enumeration Date: 01/03/2006
Last Update Date: 02/20/2025
Certification Date: 02/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6890 GREENSBORO RD
RIDGEWAY VA
24148-3555
US

IV. Provider business mailing address

6890 GREENSBORO RD
RIDGEWAY VA
24148-3555
US

V. Phone/Fax

Practice location:
  • Phone: 276-956-1013
  • Fax:
Mailing address:
  • Phone: 276-956-1013
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number2010-02034
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License Number0101241089
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number0101241089
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: