Provider Demographics
NPI:1255309399
Name:MENGESHA, NOLAWI M (MD)
Entity Type:Individual
Prefix:
First Name:NOLAWI
Middle Name:M
Last Name:MENGESHA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4400 N 32ND ST STE 140
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85018-3964
Mailing Address - Country:US
Mailing Address - Phone:602-254-4454
Mailing Address - Fax:602-254-6036
Practice Address - Street 1:4375 E IRMA LN
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85050-4312
Practice Address - Country:US
Practice Address - Phone:480-890-5800
Practice Address - Fax:480-890-5920
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2019-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ24826207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ401208Medicaid
AZZ119455Medicare PIN
104825Medicare ID - Type Unspecified
G60325Medicare UPIN