Provider Demographics
NPI:1740783315
Name:MULUGETA, SERKALEM LEYIKUN
Entity type:Individual
Prefix:
First Name:SERKALEM
Middle Name:LEYIKUN
Last Name:MULUGETA
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 1:4127 REDWOOD RD
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94619-2329
Mailing Address - Country:US
Mailing Address - Phone:510-703-2353
Mailing Address - Fax:
Practice Address - Street 1:1999 HARRISON ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94612-3520
Practice Address - Country:US
Practice Address - Phone:916-597-7166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-09
Last Update Date:2018-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA955659Medicaid