Healthcare Provider Details

I. General information

NPI: 1366462764
Provider Name (Legal Business Name): DR AFEWORKI KIDANE LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 05/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6641 E BAYWOOD AVE
MESA AZ
85206-1723
US

IV. Provider business mailing address

6641 E BAYWOOD AVE
MESA AZ
85206-1723
US

V. Phone/Fax

Practice location:
  • Phone: 480-653-8400
  • Fax: 480-209-1337
Mailing address:
  • Phone: 480-653-8400
  • Fax: 480-209-1337

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number4458
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number5101012760
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number4458
License Number StateAZ

VIII. Authorized Official

Name: AFEWORKI OCBAGHIORGIS KIDANE
Title or Position: PRESIDENT
Credential: DO
Phone: 480-653-8400