Healthcare Provider Details

I. General information

NPI: 1700025780
Provider Name (Legal Business Name): MINALESHOA H ABYE M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2009
Last Update Date: 12/21/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2151 W GRANT LINE RD
TRACY CA
95377-7309
US

IV. Provider business mailing address

600 COFFEE RD
MODESTO CA
95355-4201
US

V. Phone/Fax

Practice location:
  • Phone: 209-832-0535
  • Fax:
Mailing address:
  • Phone: 209-521-6097
  • Fax: 209-521-4081

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number063158
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number30738
License Number StateAL
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA 105237
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: