Provider Demographics
NPI:1063790392
Name:PHOOFOLO, MOJABENG (MD)
Entity type:Individual
Prefix:DR
First Name:MOJABENG
Middle Name:
Last Name:PHOOFOLO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 BRAMHALL ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-3134
Mailing Address - Country:US
Mailing Address - Phone:207-662-7068
Mailing Address - Fax:
Practice Address - Street 1:22 BRAMHALL ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-3175
Practice Address - Country:US
Practice Address - Phone:336-407-2998
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-03
Last Update Date:2024-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR166875208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist