Provider Demographics
NPI:1871916569
Name:ACHOMBOM, DERICK ABONG
Entity type:Individual
Prefix:
First Name:DERICK
Middle Name:ABONG
Last Name:ACHOMBOM
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 1:6114 BREEZEWOOD DR APT 202
Mailing Address - Street 2:
Mailing Address - City:GREENBELT
Mailing Address - State:MD
Mailing Address - Zip Code:20770-4143
Mailing Address - Country:US
Mailing Address - Phone:240-413-3166
Mailing Address - Fax:
Practice Address - Street 1:6114 BREEZEWOOD DR APT 202
Practice Address - Street 2:
Practice Address - City:GREENBELT
Practice Address - State:MD
Practice Address - Zip Code:20770-4143
Practice Address - Country:US
Practice Address - Phone:240-413-3166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-30
Last Update Date:2014-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide