Healthcare Provider Details

I. General information

NPI: 1972916823
Provider Name (Legal Business Name): DR. YOHANNES YIMER MELAKU
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2014
Last Update Date: 08/02/2023
Certification Date: 08/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 HEALTHY WAY
OCEANSIDE NY
11572-1551
US

IV. Provider business mailing address

1 HEALTHY WAY
OCEANSIDE NY
11572-1551
US

V. Phone/Fax

Practice location:
  • Phone: 212-241-6500
  • Fax:
Mailing address:
  • Phone: 212-241-6500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number305954
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD455329
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number305954
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: