Provider Demographics
NPI:1366196610
Name:FORKWA, MBOH GERALD
Entity type:Individual
Prefix:
First Name:MBOH
Middle Name:GERALD
Last Name:FORKWA
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 1:11454 STEWART LN APT C2
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20904-2231
Mailing Address - Country:US
Mailing Address - Phone:651-443-9392
Mailing Address - Fax:
Practice Address - Street 1:11454 STEWART LN APT C2
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20904-2231
Practice Address - Country:US
Practice Address - Phone:651-443-9392
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-07
Last Update Date:2022-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide