Provider Demographics
NPI:1679759088
Name:AYALEW, MELAKU (MD)
Entity Type:Individual
Prefix:DR
First Name:MELAKU
Middle Name:
Last Name:AYALEW
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 1:8439 LAKE MIST WAY
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX STATION
Mailing Address - State:VA
Mailing Address - Zip Code:22039-2676
Mailing Address - Country:US
Mailing Address - Phone:703-200-5422
Mailing Address - Fax:
Practice Address - Street 1:8439 LAKE MIST WAY
Practice Address - Street 2:
Practice Address - City:FAIRFAX STATION
Practice Address - State:VA
Practice Address - Zip Code:22039-2676
Practice Address - Country:US
Practice Address - Phone:703-200-5422
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-15
Last Update Date:2012-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0052560207R00000X, 207RA0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RA0000XAllopathic & Osteopathic PhysiciansInternal MedicineAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0101055711OtherSTATE MEDICAL LICENSE
MDD0052560OtherSTATE MEDICAL CERTIFICATE