Provider Demographics
NPI:1861454993
Name:BEYENE, SOPHIA (DO)
Entity Type:Individual
Prefix:
First Name:SOPHIA
Middle Name:
Last Name:BEYENE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:SOPHIA
Other - Middle Name:
Other - Last Name:SELASSIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 12209
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92423-2209
Mailing Address - Country:US
Mailing Address - Phone:909-335-4188
Mailing Address - Fax:
Practice Address - Street 1:1851 N RIVERSIDE AVE
Practice Address - Street 2:
Practice Address - City:RIALTO
Practice Address - State:CA
Practice Address - Zip Code:92376-8069
Practice Address - Country:US
Practice Address - Phone:909-421-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-04
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A7687207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX76870Medicaid
CAH82087Medicare UPIN
CAH82087Medicare ID - Type Unspecified