1427289339 NPI number — DR. TESFAMARIAM OKBAY METIKU M.D.

Table of content: DR. TESFAMARIAM OKBAY METIKU M.D. (NPI 1427289339)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427289339 NPI number — DR. TESFAMARIAM OKBAY METIKU M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
METIKU
Provider First Name:
TESFAMARIAM
Provider Middle Name:
OKBAY
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:
1427289339
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/08/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
19928 EDINBERG DR
Provider Second Line Business Mailing Address:
DEPT OF MEDICAL EDUCATION
Provider Business Mailing Address City Name:
MACOMB
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48044-2150
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
21409 KELLY RD STE 400
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EASTPOINTE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48021-3264
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
586-777-0630
Provider Business Practice Location Address Fax Number:
586-777-0631
Provider Enumeration Date:
07/28/2009

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:  4301092621 , 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)





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