Provider Demographics
NPI:1588979884
Name:AMDEMICHAEL, EYOB A (MD)
Entity type:Individual
Prefix:
First Name:EYOB
Middle Name:A
Last Name:AMDEMICHAEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11215 OAK LEAF DR APT 301
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20901-1365
Mailing Address - Country:US
Mailing Address - Phone:202-834-3428
Mailing Address - Fax:202-834-3428
Practice Address - Street 1:11215 OAK LEAF DR APT 301
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20901-1365
Practice Address - Country:US
Practice Address - Phone:202-834-3428
Practice Address - Fax:866-357-8609
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-11
Last Update Date:2014-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2013-0563207R00000X
PAMD449260207R00000X
MN56794207R00000X
ND12986207R00000X
MA256979207R00000X
VA101255547207R00000X
MDD0077556207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM326011YS5YOtherMEDICARE
NM64081770Medicaid