Provider Demographics
NPI:1588752778
Name:AYELE, ETSEGENET T (MD)
Entity type:Individual
Prefix:
First Name:ETSEGENET
Middle Name:T
Last Name:AYELE
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 1:5122 KATELLA AVE STE 210
Mailing Address - Street 2:
Mailing Address - City:LOS ALAMITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90720-6836
Mailing Address - Country:US
Mailing Address - Phone:562-598-0600
Mailing Address - Fax:562-598-0678
Practice Address - Street 1:5122 KATELLA AVE STE 210
Practice Address - Street 2:
Practice Address - City:LOS ALAMITOS
Practice Address - State:CA
Practice Address - Zip Code:90720-6836
Practice Address - Country:US
Practice Address - Phone:562-598-0600
Practice Address - Fax:562-598-0678
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA667410207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A667410Medicaid
CA00A667410Medicaid
CAWA66741EMedicare ID - Type Unspecified