Provider Demographics
NPI:1902528326
Name:MBOM, SIXTUS
Entity Type:Individual
Prefix:
First Name:SIXTUS
Middle Name:
Last Name:MBOM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6933 LAMONT DR
Mailing Address - Street 2:
Mailing Address - City:LANHAM
Mailing Address - State:MD
Mailing Address - Zip Code:20706-4606
Mailing Address - Country:US
Mailing Address - Phone:302-898-2114
Mailing Address - Fax:
Practice Address - Street 1:1418 GOOD HOPE RD SE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20020-5615
Practice Address - Country:US
Practice Address - Phone:302-898-2114
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-13
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator