Provider Demographics
NPI:1962938803
Name:NGWAFANG, BLECK B (MD)
Entity type:Individual
Prefix:
First Name:BLECK
Middle Name:B
Last Name:NGWAFANG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13540 HULL STREET RD
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23112-2107
Mailing Address - Country:US
Mailing Address - Phone:804-739-6142
Mailing Address - Fax:
Practice Address - Street 1:13540 HULL STREET RD
Practice Address - Street 2:C/O TONYA AGOSTO
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23112-2107
Practice Address - Country:US
Practice Address - Phone:804-739-6142
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-11
Last Update Date:2021-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA101267223207Q00000X
VA0101267223208M00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist