Provider Demographics
NPI:1326018557
Name:KIDANE, AFEWORKI OCBAGHIORGIS (DO)
Entity Type:Individual
Prefix:MR
First Name:AFEWORKI
Middle Name:OCBAGHIORGIS
Last Name:KIDANE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3003 N CENTRAL AVE STE 1175
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-0002
Mailing Address - Country:US
Mailing Address - Phone:888-698-6727
Mailing Address - Fax:602-564-6246
Practice Address - Street 1:1985 E CHANDLER BLVD
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85225-5110
Practice Address - Country:US
Practice Address - Phone:602-755-0800
Practice Address - Fax:602-560-2721
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2022-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4458204D00000X, 207R00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3480230Medicaid
MIG81180Medicare UPIN
MI0B56065007Medicare ID - Type Unspecified