Provider Demographics
NPI:1992967632
Name:MITIKE, MESFIN TESHOME (MD)
Entity type:Individual
Prefix:
First Name:MESFIN
Middle Name:TESHOME
Last Name:MITIKE
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:PO BOX 955534
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63195-5534
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1035 BELLEVUE AVE
Practice Address - Street 2:SUITE 500
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63117-1854
Practice Address - Country:US
Practice Address - Phone:314-925-4744
Practice Address - Fax:314-925-4764
Is Sole Proprietor?:No
Enumeration Date:2008-06-25
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20120118542084S0012X
MO20080137092084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084S0012XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologySleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO991373069Medicare PIN