Provider Demographics
NPI:1215418413
Name:WOLDE, MIKIAS
Entity Type:Individual
Prefix:
First Name:MIKIAS
Middle Name:
Last Name:WOLDE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:812 NORTHWEST DR
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20901-1434
Mailing Address - Country:US
Mailing Address - Phone:301-385-9184
Mailing Address - Fax:
Practice Address - Street 1:34 MAPLE ST
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:CT
Practice Address - Zip Code:06850-3894
Practice Address - Country:US
Practice Address - Phone:203-852-2188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-24
Last Update Date:2018-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Multi-Specialty