Provider Demographics
NPI:1376579417
Name:ABDISSA, MESFIN ETANA (MD)
Entity Type:Individual
Prefix:
First Name:MESFIN
Middle Name:ETANA
Last Name:ABDISSA
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 1:1000 DEVONSHIRE LN APT A116
Mailing Address - Street 2:A116
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55431-5032
Mailing Address - Country:US
Mailing Address - Phone:240-893-7484
Mailing Address - Fax:
Practice Address - Street 1:6901 W EDGERTON AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53220-4420
Practice Address - Country:US
Practice Address - Phone:414-423-5179
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-23
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI48957207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34871300Medicaid
WIBA6935713OtherDEA REGISTRATION
WII53521Medicare ID - Type Unspecified