Provider Demographics
NPI:1194923961
Name:MAMMO, TIGIST NIGATU (MD)
Entity type:Individual
Prefix:
First Name:TIGIST
Middle Name:NIGATU
Last Name:MAMMO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1881 NANI ST
Mailing Address - Street 2:
Mailing Address - City:WAILUKU
Mailing Address - State:HI
Mailing Address - Zip Code:96793-1811
Mailing Address - Country:US
Mailing Address - Phone:808-871-7772
Mailing Address - Fax:
Practice Address - Street 1:1881 NANI ST
Practice Address - Street 2:
Practice Address - City:WAILUKU
Practice Address - State:HI
Practice Address - Zip Code:96793-1811
Practice Address - Country:US
Practice Address - Phone:808-871-7772
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-03
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101250000207R00000X, 208000000X
HIMD-16389207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics