Provider Demographics
NPI:1639867567
Name:TIZAZU, MULUNEH MEKUANENT
Entity type:Individual
Prefix:
First Name:MULUNEH
Middle Name:MEKUANENT
Last Name:TIZAZU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6165 LEHMAN DR STE 203-7
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80918-3441
Mailing Address - Country:US
Mailing Address - Phone:720-231-2805
Mailing Address - Fax:
Practice Address - Street 1:1420 MOLINE ST APT 306
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80010-3628
Practice Address - Country:US
Practice Address - Phone:720-231-2805
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-27
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO071210632172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver