Healthcare Provider Details

I. General information

NPI: 1609454024
Provider Name (Legal Business Name): ANDENET MENGISTU MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2021
Last Update Date: 07/23/2025
Certification Date: 07/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 N STATE ST
JACKSON MS
39216-4500
US

IV. Provider business mailing address

1600 MEDICAL CENTER DR
HUNTINGTON WV
25701-3656
US

V. Phone/Fax

Practice location:
  • Phone: 601-984-4820
  • Fax:
Mailing address:
  • Phone: 304-691-1824
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License NumberT-5943
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: