1831155787 NPI number — DR. MEZGEBE BERHE MD

Table of content: DR. MEZGEBE BERHE MD (NPI 1831155787)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831155787 NPI number — DR. MEZGEBE BERHE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BERHE
Provider First Name:
MEZGEBE
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1831155787
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/12/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3409 WORTH ST
Provider Second Line Business Mailing Address:
710
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75246-2029
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
214-823-2533
Provider Business Mailing Address Fax Number:
214-824-8679

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3409 WORTH ST
Provider Second Line Business Practice Location Address:
710
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75246-2029
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-823-2533
Provider Business Practice Location Address Fax Number:
214-824-8679
Provider Enumeration Date:
04/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  M1510 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RI0200X , with the licence number: M1510 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 177738501 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1143000 . This is a "AETNA" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: M1510 . This is a "STATE LICENSE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 8J3801 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: MD1510 . This is a "WORKERS COMP" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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