Provider Demographics
NPI:1881377935
Name:DEMSSIE, MELAKU DAMTE
Entity type:Individual
Prefix:
First Name:MELAKU
Middle Name:DAMTE
Last Name:DEMSSIE
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 1:4985 MARKET ST APT 315
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92102-4730
Mailing Address - Country:US
Mailing Address - Phone:619-252-5846
Mailing Address - Fax:
Practice Address - Street 1:4985 MARKET ST APT 315
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92102-4730
Practice Address - Country:US
Practice Address - Phone:619-252-5846
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-07
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA38504Z1347E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347E00000XTransportation ServicesTransportation Broker