Healthcare Provider Details

I. General information

NPI: 1548897994
Provider Name (Legal Business Name): MIKIYAS TESHOME DESTA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2020
Last Update Date: 07/03/2026
Certification Date: 07/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5901 HARPER DR NE
ALBUQUERQUE NM
87109-3587
US

IV. Provider business mailing address

PO BOX 26666 PHS PROVIDER ENROLLMENT
ALBUQUERQUE NM
87125-6666
US

V. Phone/Fax

Practice location:
  • Phone: 505-823-8200
  • Fax: 505-823-8579
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberMD2025-0810
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: