Provider Demographics
NPI:1023222619
Name:MEKONNEN, LEGESSE (MD)
Entity type:Individual
Prefix:
First Name:LEGESSE
Middle Name:
Last Name:MEKONNEN
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 1:9305 W THOMAS RD
Mailing Address - Street 2:SUITE 380
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85037-3328
Mailing Address - Country:US
Mailing Address - Phone:623-327-4144
Mailing Address - Fax:623-327-4140
Practice Address - Street 1:9305 W THOMAS RD
Practice Address - Street 2:SUITE 380
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85037-3328
Practice Address - Country:US
Practice Address - Phone:623-327-4144
Practice Address - Fax:623-327-4140
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2011-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ44627207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ145905Medicare PIN