Provider Demographics
NPI:1346251568
Name:MAMO, DAWIT (MD)
Entity Type:Individual
Prefix:
First Name:DAWIT
Middle Name:
Last Name:MAMO
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:PO BOX 3800
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92307-0074
Mailing Address - Country:US
Mailing Address - Phone:760-242-4000
Mailing Address - Fax:760-242-5250
Practice Address - Street 1:16070 TUSCOLA RD
Practice Address - Street 2:SUITE 101
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92307-1320
Practice Address - Country:US
Practice Address - Phone:760-242-4000
Practice Address - Fax:760-242-5250
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2008-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA54482207Q00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A544820Medicaid
P00617260Medicare PIN
F84197Medicare UPIN
CA00A544820Medicaid