Provider Demographics
NPI:1972769339
Name:MBANUZUE, QUEEN (DPM)
Entity type:Individual
Prefix:
First Name:QUEEN
Middle Name:
Last Name:MBANUZUE
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 683
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20718-0683
Mailing Address - Country:US
Mailing Address - Phone:301-430-0337
Mailing Address - Fax:
Practice Address - Street 1:2905 MITCHELLVILLE RD STE 105
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20716
Practice Address - Country:US
Practice Address - Phone:301-430-0337
Practice Address - Fax:240-244-0617
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-05
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD01494213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD043167200Medicaid
MD834112500Medicaid
MD1245527258OtherNPI