Basic Information
| Provider Information | |||||||||
| NPI: | 1831155787 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BERHE | ||||||||
| FirstName: | MEZGEBE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | |||||||||
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| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 3409 WORTH ST | ||||||||
| Address2: | 710 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752462029 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2148232533 | ||||||||
| FaxNumber: | 2148248679 | ||||||||
| Practice Location | |||||||||
| Address1: | 3409 WORTH ST | ||||||||
| Address2: | 710 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752462029 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2148232533 | ||||||||
| FaxNumber: | 2148248679 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2006 | ||||||||
| LastUpdateDate: | 08/02/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | M1510 | TX | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | MD1510 | 01 | TX | WORKERS COMP | OTHER | 177738501 | 05 | TX | MEDICAID | 8J3801 | 01 | TX | BLUE CROSS BLUE SHIELD | OTHER | 1143000 | 01 | TX | AETNA | OTHER | M1510 | 01 | TX | STATE LICENSE | OTHER |