Provider Demographics
NPI:1427445378
Name:MENGISTU, GETACHEW
Entity type:Individual
Prefix:
First Name:GETACHEW
Middle Name:
Last Name:MENGISTU
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 1:1113 W NOLCREST DR
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20903-1043
Mailing Address - Country:US
Mailing Address - Phone:240-863-8756
Mailing Address - Fax:
Practice Address - Street 1:2001 MEDICAL PKWY
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-3773
Practice Address - Country:US
Practice Address - Phone:443-481-1000
Practice Address - Fax:443-481-1687
Is Sole Proprietor?:No
Enumeration Date:2015-04-17
Last Update Date:2018-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MDD086150207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program