Healthcare Provider Details

I. General information

NPI: 1992967632
Provider Name (Legal Business Name): MESFIN TESHOME MITIKE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2008
Last Update Date: 11/23/2020
Certification Date: 11/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1035 BELLEVUE AVE SUITE 500
SAINT LOUIS MO
63117-1854
US

IV. Provider business mailing address

PO BOX 955534
SAINT LOUIS MO
63195-5534
US

V. Phone/Fax

Practice location:
  • Phone: 314-925-4744
  • Fax: 314-925-4764
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084S0012X
TaxonomySleep Medicine (Psychiatry & Neurology) Physician
License Number2012011854
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number2008013709
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: