Provider Demographics
NPI:1366462764
Name:DR AFEWORKI KIDANE LTD
Entity Type:Organization
Organization Name:DR AFEWORKI KIDANE LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:AFEWORKI
Authorized Official - Middle Name:OCBAGHIORGIS
Authorized Official - Last Name:KIDANE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:480-653-8400
Mailing Address - Street 1:6641 E BAYWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-1723
Mailing Address - Country:US
Mailing Address - Phone:480-653-8400
Mailing Address - Fax:480-209-1337
Practice Address - Street 1:6641 E BAYWOOD AVE
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-1723
Practice Address - Country:US
Practice Address - Phone:480-653-8400
Practice Address - Fax:480-209-1337
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-20
Last Update Date:2018-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4458204D00000X, 261Q00000X
MI5101012760207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMMGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
168550OtherACCCS AZ
MI3480230Medicaid
168550OtherACCCS AZ
MI3480230Medicaid