Provider Demographics
NPI:1013722636
Name:FONGANG, OCTAVIUS ATUD
Entity type:Individual
Prefix:
First Name:OCTAVIUS
Middle Name:ATUD
Last Name:FONGANG
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 1:12515 SABER LN
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20715-2220
Mailing Address - Country:US
Mailing Address - Phone:240-825-8245
Mailing Address - Fax:
Practice Address - Street 1:12515 SABER LN
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20715-2220
Practice Address - Country:US
Practice Address - Phone:240-825-8245
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-11
Last Update Date:2025-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty