Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 204D00000X | Neuromusculoskeletal Medicine (NMM) | 4458 | AZ |
Y | 207R00000X | Internist | 4458 | AZ |
Y | 111NI0900X | Internist | 4458 | AZ |
N | 207R00000X | Internist | 5101012760 | MI |
N | 111NI0900X | Internist | 5101012760 | MI |
NPI | 1326018557 |
---|---|
Provider Name | Mr. Afeworki Ocbaghiorgis Kidane |
First Address | Mesa, AZ 85206-1723 |
Second Address | Mesa, AZ 85206-1723 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 23/01/2006 |
Last Update Date | 11/05/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
3480230 | (05) | MI |
G81180 | (02) | MI |