Provider Demographics
NPI:1205875143
Name:TEFERRA, MESERET
Entity type:Individual
Prefix:DR
First Name:MESERET
Middle Name:
Last Name:TEFERRA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 24116
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39225-4116
Mailing Address - Country:US
Mailing Address - Phone:601-362-5321
Mailing Address - Fax:601-364-2600
Practice Address - Street 1:1551 W GOVERNMENT ST
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:MS
Practice Address - Zip Code:39042-2408
Practice Address - Country:US
Practice Address - Phone:601-825-7280
Practice Address - Fax:601-825-8130
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2016-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS19108207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02378381Medicaid
MSI48815Medicare UPIN
MS110001941Medicare Oscar/Certification