Provider Demographics
NPI:1700025780
Name:ABYE, MINALESHOA H (MD)
Entity Type:Individual
Prefix:
First Name:MINALESHOA
Middle Name:H
Last Name:ABYE
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 1:600 COFFEE RD
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-4201
Mailing Address - Country:US
Mailing Address - Phone:209-521-6097
Mailing Address - Fax:209-521-4081
Practice Address - Street 1:2151 W GRANT LINE RD
Practice Address - Street 2:
Practice Address - City:TRACY
Practice Address - State:CA
Practice Address - Zip Code:95377-7309
Practice Address - Country:US
Practice Address - Phone:209-832-0535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-13
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA063158208000000X
AL30738208000000X
CAA 105237208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL126765Medicaid