Provider Demographics
NPI:1700545407
Name:MUDOH, CLOVIS M
Entity type:Individual
Prefix:
First Name:CLOVIS M
Middle Name:
Last Name:MUDOH
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 1:9601 GOOD LUCK RD
Mailing Address - Street 2:
Mailing Address - City:LANHAM
Mailing Address - State:MD
Mailing Address - Zip Code:20706-3637
Mailing Address - Country:US
Mailing Address - Phone:240-877-5084
Mailing Address - Fax:
Practice Address - Street 1:9601 GOOD LUCK RD
Practice Address - Street 2:
Practice Address - City:LANHAM
Practice Address - State:MD
Practice Address - Zip Code:20706-3637
Practice Address - Country:US
Practice Address - Phone:240-877-5084
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-10
Last Update Date:2021-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide