Provider Demographics
NPI:1174198444
Name:MENGSTU, ABRAHAM YBRAH
Entity Type:Individual
Prefix:
First Name:ABRAHAM
Middle Name:YBRAH
Last Name:MENGSTU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:ABRAHA
Other - Middle Name:YBRAH
Other - Last Name:MENGSTU
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:16001 W 9 MILE RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-4818
Mailing Address - Country:US
Mailing Address - Phone:248-849-2203
Mailing Address - Fax:248-849-5395
Practice Address - Street 1:16001 W 9 MILE RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-4818
Practice Address - Country:US
Practice Address - Phone:248-849-2203
Practice Address - Fax:248-849-5395
Is Sole Proprietor?:No
Enumeration Date:2021-05-20
Last Update Date:2021-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI43510485132085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program