Provider Demographics
NPI:1699266684
Name:MAKONNEN, SAMSON N/A (MD)
Entity type:Individual
Prefix:
First Name:SAMSON
Middle Name:N/A
Last Name:MAKONNEN
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 1:2740 HUNTERGATE TERRACE
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20904
Mailing Address - Country:US
Mailing Address - Phone:510-508-6893
Mailing Address - Fax:
Practice Address - Street 1:765 KENILWORTH TER NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20019-1898
Practice Address - Country:US
Practice Address - Phone:202-469-4699
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-24
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
DCMD210001506208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program