1316096522 NPI number — DR. TEFERI YILMA MITIKU M.D.

Table of content: (NPI 1316019227)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316096522 NPI number — DR. TEFERI YILMA MITIKU M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MITIKU
Provider First Name:
TEFERI
Provider Middle Name:
YILMA
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1316096522
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/08/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
333 CORPORATE DR
Provider Second Line Business Mailing Address:
STE 102
Provider Business Mailing Address City Name:
LADERA RANCH
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92694-2113
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-456-3868
Provider Business Mailing Address Fax Number:
313-745-4399

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 CITY DRIVE SOUTH
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ORANGE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92868
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-456-3868
Provider Business Practice Location Address Fax Number:
313-745-4399
Provider Enumeration Date:
01/09/2007

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: 207R00000X , with the licence number:  A92724 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: 4301101657 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RC0000X , with the licence number: 4301101657 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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