Provider Demographics
NPI:1215671599
Name:DIKANDA, MUTEBA
Entity type:Individual
Prefix:
First Name:MUTEBA
Middle Name:
Last Name:DIKANDA
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 1:358 SW VIOLET AVE
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34983-1971
Mailing Address - Country:US
Mailing Address - Phone:772-985-2557
Mailing Address - Fax:
Practice Address - Street 1:3200 N ALAFAYA TRL APT 2416
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32826-2850
Practice Address - Country:US
Practice Address - Phone:772-985-2557
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-23
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program