Provider Demographics
NPI:1720571136
Name:FEKENE, TAMIRAT EDIE (MD)
Entity Type:Individual
Prefix:
First Name:TAMIRAT
Middle Name:EDIE
Last Name:FEKENE
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 1:5826 104TH ST
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79424-8282
Mailing Address - Country:US
Mailing Address - Phone:206-430-8671
Mailing Address - Fax:
Practice Address - Street 1:222 S WOODS MILL RD
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-3625
Practice Address - Country:US
Practice Address - Phone:314-205-6050
Practice Address - Fax:314-434-5939
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-11
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018012258207R00000X
NMMD2022-0215207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine