Provider Demographics
NPI:1427030824
Name:HAILU, MEKDES
Entity Type:Individual
Prefix:
First Name:MEKDES
Middle Name:
Last Name:HAILU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:317 E 17TH ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10003-3804
Mailing Address - Country:US
Mailing Address - Phone:212-420-2885
Mailing Address - Fax:
Practice Address - Street 1:317 E 17TH ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-3804
Practice Address - Country:US
Practice Address - Phone:212-420-2885
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-19
Last Update Date:2012-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY222289207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYH11048HMedicare UPIN