Momodu A Jack, M.D.
Individual provider Active NPI Gastroenterology Physician · Washington, DC
NPI 1164521019 · NPPES record last updated Nov 6, 2020
Key facts
- NPI
- 1164521019
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Gastroenterology Physician 207RG0100X
- License
- MD20286 (DC)
- Practice address
- 2139 Georgia Ave NW
Suite 3a
Washington, DC 20001-3035 - Phone
- (202) 865-7981
- Fax
- (301) 621-5313
- NPI assigned
- Sep 21, 2006
- Sex
- Male
- Sole proprietor
- Yes
Organizations & group practices 2
Hospital & facility affiliations 1
Medicare Care Compare profile
- Specialty
- Gastroenterology
- Education
- Other, 1985
- Medicare assignment
- Accepts the Medicare-approved amount as payment in full
Practice addresses (Care Compare)
2139 Georgia Ave NW
Suite 3a
Washington, DC 20001-3006
Phone (202) 865-7981
Hospital & facility affiliations
- Howard University Hospital Corp
Procedures performed for Medicare patients
| Procedure | Number of procedures |
|---|---|
| Colonoscopy | 229 |
| Upper gastrointestinal (GI) endoscopy for acid reflux | 41 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in DC, VA
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: Yes · Hospice: Yes
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20101109000138 | DC | Practitioner - Gastroenterology |
4981899648 | Practice locations: Washington, DC |
| I20191228000368 | VA | Practitioner - Gastroenterology |
4981899648 | Reassigns benefits to 1 organization |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| MD20286 | DC | MD | Gastroenterology Physician |
| D0044035 | MD | MD | Gastroenterology Physician |
| 0101270422 | VA | MD | Interventional Pain Medicine Physician |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Privia Medical Group, LLC | Gastroenterology | Current |
Accepting new patients |
| Privia Medical Group, LLC | Current |
Accepting new patients |
Locations
541 Sunset Ln
Ste 301
Culpeper, VA 22701
Phone (540) 825-4557
15237 Creativity Dr
Culpeper, VA 22701
Phone (540) 321-4281
8644 Sudley Rd
#220
Manassas, VA 20110
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Gastroenterology Physician | 207RG0100X | D0044035 | MD | |
| Gastroenterology Physician | 207RG0100X | 0101270422 | VA | |
| Gastroenterology Physician | 207RG0100X | MD20286 | DC | Yes |
Addresses
Primary practice location
2139 Georgia Ave NW
Suite 3a
Washington, DC 20001-3035
Mailing address
PO Box 2325
Columbia, MD 21045-1325
Phone (202) 865-7981
Other practice location 1
541 Sunset Ln Ste 301
Culpeper, VA 22701-3979
Phone (540) 825-4557
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 0101267872 | Other | VA | LICENSE |
| 174961700 | Medicaid | MD | |
| 018868500 | Medicaid | DC |
Other providers in Washington, DC
- Marilyne T Jabosung
- Jack Burton Strength and Conditioning LLC
- Fay D Jack
- Joanne Jack
- Lennard Jack Jr.
- Ebonique Jacks
- Iman Jacks
- Jackson Marriage and Family Counseling Services
- Latosha Jackson Martin
- Anjelica E Jackson Todd
All providers in Washington, DC · Gastroenterology Physician in District of Columbia
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Nov 6, 2020. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.