Healthcare Provider Details

I. General information

NPI: 1265372403
Provider Name (Legal Business Name): MIKIAS BERHANU NEGUSSIE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: MIKIAS B NEGUSSIE MD

II. Dates (important events)

Enumeration Date: 03/30/2026
Last Update Date: 03/30/2026
Certification Date: 03/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1329 GROVE ST
SAN FRANCISCO CA
94117-1481
US

IV. Provider business mailing address

1329 GROVE ST
SAN FRANCISCO CA
94117-1481
US

V. Phone/Fax

Practice location:
  • Phone: 720-862-5194
  • Fax:
Mailing address:
  • Phone: 720-862-5194
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: