Basic Information
| Provider Information | |||||||||
| NPI: | 1134392483 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MULUGETA | ||||||||
| FirstName: | LEUL | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4000 COLISEUM DR | ||||||||
| Address2: | STE 445 | ||||||||
| City: | HAMPTON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 236665906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7578272127 | ||||||||
| FaxNumber: | 7578272255 | ||||||||
| Practice Location | |||||||||
| Address1: | 4000 COLISEUM DR | ||||||||
| Address2: | STE. 350 | ||||||||
| City: | HAMPTON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 236665906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7577361000 | ||||||||
| FaxNumber: | 7578272255 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2008 | ||||||||
| LastUpdateDate: | 03/28/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 0101243060 | VA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1134392483 | 05 | VA | MEDICAID |