Provider Demographics
NPI:1164515672
Name:MENGISTU, MEAZA MULUGETA (MD)
Entity Type:Individual
Prefix:
First Name:MEAZA
Middle Name:MULUGETA
Last Name:MENGISTU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3510 CAMBRIDGE COURT APT 103
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:61832
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1900 EAST MAIN ST
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61832
Practice Address - Country:US
Practice Address - Phone:217-554-4510
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine