Provider Demographics
NPI:1528030277
Name:MEBRAHTU, SAMSON (MD)
Entity Type:Individual
Prefix:DR
First Name:SAMSON
Middle Name:
Last Name:MEBRAHTU
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 1:712 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11751-3620
Mailing Address - Country:US
Mailing Address - Phone:631-758-4444
Mailing Address - Fax:
Practice Address - Street 1:280 MONTAUK HWY
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-8403
Practice Address - Country:US
Practice Address - Phone:631-758-4444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-06
Last Update Date:2017-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1777952084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01340981Medicaid
NY70F661Medicare ID - Type Unspecified
NY01340981Medicaid