Healthcare Provider Details

I. General information

NPI: 1043081888
Provider Name (Legal Business Name): ABIGYA MELAKU MAMO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MELAKU MAMO

II. Dates (important events)

Enumeration Date: 01/10/2024
Last Update Date: 03/31/2025
Certification Date: 03/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2147 ABBOTT ST
SAN DIEGO CA
92107-2031
US

IV. Provider business mailing address

995 GATEWAY CENTER WAY STE 300
SAN DIEGO CA
92102-4550
US

V. Phone/Fax

Practice location:
  • Phone: 619-923-1920
  • Fax:
Mailing address:
  • Phone: 619-398-2156
  • Fax: 619-398-2168

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: