Healthcare Provider Details

I. General information

NPI: 1629455936
Provider Name (Legal Business Name): MEBRATU DABA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2015
Last Update Date: 11/05/2021
Certification Date: 11/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4348 ELECTRIC RD
ROANOKE VA
24018-0720
US

IV. Provider business mailing address

102 HIGHLAND AVE SE STE 104
ROANOKE VA
24013-2255
US

V. Phone/Fax

Practice location:
  • Phone: 540-769-0976
  • Fax: 540-587-5392
Mailing address:
  • Phone: 540-985-8147
  • Fax: 540-985-8435

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101264832
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: