Provider Demographics
NPI:1902825870
Name:MELAKEHIWOT REGASSA, ADDISALEM (MD)
Entity Type:Individual
Prefix:
First Name:ADDISALEM
Middle Name:
Last Name:MELAKEHIWOT REGASSA
Suffix:
Gender:F
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:ONE BROOKDALE PLAZA
Mailing Address - Street 2:PHYSICIAN ENTERPRISE
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11212-4230
Mailing Address - Country:US
Mailing Address - Phone:718-240-7143
Mailing Address - Fax:718-240-5808
Practice Address - Street 1:1873 EASTERN PKWY
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11233-3214
Practice Address - Country:US
Practice Address - Phone:718-240-8700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2020-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY220574207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01801409Medicaid
NYG63735Medicare UPIN
NY01801409Medicaid