Provider Demographics
NPI:1588418511
Name:FONSAH FONDECK, PAUL
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:FONSAH FONDECK
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 1:5915 CHERRYWOOD LN APT 203
Mailing Address - Street 2:
Mailing Address - City:GREENBELT
Mailing Address - State:MD
Mailing Address - Zip Code:20770-4257
Mailing Address - Country:US
Mailing Address - Phone:301-910-4160
Mailing Address - Fax:
Practice Address - Street 1:702 15TH ST NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20002-4508
Practice Address - Country:US
Practice Address - Phone:202-388-8005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-16
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker