NPI Code Detail JSON Logo

1164521019 NPI number — MOMODU A JACK M.D.

NPI Number: 1164521019
Health Care Provider/Practitioner: MOMODU A JACK M.D.

Information about “1164521019” NPI (MOMODU A JACK M.D.) exists in 1164521019 in HTML format HTML  |  1164521019 in plain Text format TXT  |  1164521019 in PDF (Portable Document Format) PDF  |  1164521019 in an XML format XML  formats.

NPI Number : 1164521019 – JSON Data Format

                
{
  "Npi": {
    "NPI": "1164521019",
    "EntityType": "Individual",
    "ReplacementNPI": null,
    "EIN": null,
    "IsSoleProprietor": "Y",
    "IsOrgSubpart": null,
    "ParentOrgLBN": null,
    "ParentOrgTIN": null,
    "OrgName": null,
    "LastName": "JACK",
    "FirstName": "MOMODU",
    "MiddleName": "A",
    "NamePrefix": null,
    "NameSuffix": null,
    "Credential": "M.D.",
    "OtherOrgName": null,
    "OtherOrgNameTypeCode": null,
    "OtherLastName": null,
    "OtherFirstName": null,
    "OtherMiddleName": null,
    "OtherNamePrefix": null,
    "OtherNameSuffix": null,
    "OtherCredential": null,
    "OtherLastNameTypeCode": null,
    "FirstLineMailingAddress": "PO BOX 2325",
    "SecondLineMailingAddress": null,
    "MailingAddressCityName": "COLUMBIA",
    "MailingAddressStateName": "MD",
    "MailingAddressPostalCode": "21045-1325",
    "MailingAddressCountryCode": "US",
    "MailingAddressTelephoneNumber": "202-865-7981",
    "MailingAddressFaxNumber": "301-621-5313",
    "FirstLinePracticeLocationAddress": "2139 GEORGIA AVE NW",
    "SecondLinePracticeLocationAddress": "SUITE 3A",
    "PracticeLocationAddressCityName": "WASHINGTON",
    "PracticeLocationAddressStateName": "DC",
    "PracticeLocationAddressPostalCode": "20001-3035",
    "PracticeLocationAddressCountryCode": "US",
    "PracticeLocationAddressTelephoneNumber": "202-865-7981",
    "PracticeLocationAddressFaxNumber": "301-621-5313",
    "EnumerationDate": "09/21/2006",
    "LastUpdateDate": "11/06/2020",
    "NPIDeactivationReasonCode": null,
    "NPIDeactivationReason": null,
    "NPIDeactivationDate": null,
    "NPIReactivationDate": null,
    "GenderCode": "M",
    "Gender": "Male",
    "AuthorizedOfficialLastName": null,
    "AuthorizedOfficialFirstName": null,
    "AuthorizedOfficialMiddleName": null,
    "AuthorizedOfficialTitle": null,
    "AuthorizedOfficialNamePrefix": null,
    "AuthorizedOfficialNameSuffix": null,
    "AuthorizedOfficialCredential": null,
    "AuthorizedOfficialTelephoneNumber": null,
    "Taxonomies": {
      "Taxonomy": [
        {
          "TaxonomyCode": "207RG0100X",
          "TaxonomyName": "Gastroenterology Physician",
          "LicenseNumber": "D0044035",
          "LicenseNumberStateCode": "MD",
          "PrimaryTaxonomySwitch": "N"
        },
        {
          "TaxonomyCode": "207RG0100X",
          "TaxonomyName": "Gastroenterology Physician",
          "LicenseNumber": "0101270422",
          "LicenseNumberStateCode": "VA",
          "PrimaryTaxonomySwitch": "N"
        },
        {
          "TaxonomyCode": "207RG0100X",
          "TaxonomyName": "Gastroenterology Physician",
          "LicenseNumber": "MD20286",
          "LicenseNumberStateCode": "DC",
          "PrimaryTaxonomySwitch": "Y"
        }
      ]
    },
    "HealthcareProviderTaxonomyGroups": null
  }
}
                
            

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