Provider Demographics
NPI:1053622399
Name:KEBEDE, MIKIAS ABEBE
Entity type:Individual
Prefix:
First Name:MIKIAS
Middle Name:ABEBE
Last Name:KEBEDE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:MIKIAS
Other - Middle Name:A
Other - Last Name:KEBEDE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 173862
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80217-3862
Mailing Address - Country:US
Mailing Address - Phone:303-306-7783
Mailing Address - Fax:303-306-7753
Practice Address - Street 1:501 E HAMPDEN AVE
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80113-2702
Practice Address - Country:US
Practice Address - Phone:303-788-6911
Practice Address - Fax:303-306-7753
Is Sole Proprietor?:No
Enumeration Date:2010-07-01
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0053823207R00000X, 208M00000X
VA0101253543207R00000X, 208M00000X
WI60590207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO75104067Medicaid
COP01373719OtherRAIL ROAD MEDICARE
CO75104067Medicaid