Background: Tuberculosis ( TB) r emains a m ajor global h ealth pr oblem and r anks a s t he s econd leading cause o f d eath am ong d eaths cau sed b y i nfectious d iseases w orldwide. D espite t he availability o f s hort c ourse r egimens as f irst l ine a nti tu berculosis d rugs, e mergence of d rug resistant Mycobacterium tuberculosis strains pose a major challenge to the prevention and control efforts of national t uberculosis programs (NTPs). In developing countries, i ncluding Ethiopia, t he burden of tuberculosis and /or drug resistance profile of M.tuberculosis remains largely unexplored, mainly due to lack of quality controlled second line laboratory tests. Objectives: To as sess t he m ycobacterial genotypic diversity a nd dr ug r esistance pa ttern of M. tuberculosis complex in North West Ethiopia: resource limited settings. Moreover, it w as to assess the knowledge, attitude and practice (KAP) of TB suspects towards tuberculosis Methods: Health care institution-based cross-sectional study was designed and conducted to assess: 1) Mycobacterial strain diversity 2) drug resistance pattern of Mycobacterium tuberculosis and 3) to evaluate th e KAP o f T B s uspects to wards T B in N orth W est E thiopia: r esource limite d s ettings. Study Subjects from health facilities in Benishangul Gumuz region and Awi zone of Amhara region who consented to participate were included in the study. 112 Smear positive samples were collected from study participants, stored and transported to Armauer H ansen Research Institute (AHRI) T B laboratory. A t A HRI l aboratory Lowenstein–Jensen (LJ) culture, d rug s usceptibility te sting, R D9 deletion t yping a nd S poligotyping w ere pe rformed f rom A pril 2013 t hrough J une 2014. D rug susceptibility te sting (DST) was done b y t he p roportion m ethod on 24 w ell pl ates us ing 7H 10 medium. T he i solates w ere f urther c haracterized b y spoligotyping a nd compared w ith updated SpolDB4.0 database to identify the circulating strains. Information for KAP study was collected on well-structured questionnaires. SPSS V.20 statistical software was used for data entry, data cleaning and analysis. Results: DST result of isolates from 87 samples showed one or more drug resistance in 16.5% with higher r ate o f m onoresistance t o i soniazid ( 6.9%). M ultidrug r esistance o f 2( 2.3%) w as obs erved with 1(1.3%) and 1(8.3%) distribution among new and retreatment cases respectively. From 75 Mycobacterium t uberculosis isolates typed, 39 pa rticular s poligotype pa tterns w ith 32(42.7%) of “New” i solates was observed. S IT289, S IT53, S IT149, S IT37 and S IT134 were t he predominant s trains circulating i n t he s tudy region with proportion of 14.7%, 12.0%, 8.0%, 5.3% and 4.0% respectively From 383 pa rticipants i nvolved f or K AP s tudy 231( 60.3%) w ere m ale a nd 152( 39.7%) were female. M ost frequent r espondents’ s ources of i nformation about TB were health professionals in 131(34.2%) and 20( 5.2%) had never h eard a bout t uberculosis. 254( 66.3%) kne w t hat T B transmission i s a erosol w hile 81( 21.1%) do not know a bout i t. 22 3(58.2%) r esponded T B transmission c an b e p revented b y covering m outh a nd nos e w hile c oughing and s neezing but 125(32.6%) do not kn ow a bout m eans o f T B pr evention. Respondents’ l ack of know ledge 169(49.6%) and 63(18.5%) were r easoned accessibility an d affordability for t heir de lay i n health service seeking behavior. Conclusion: Although c urrent l evel of dr ug r esistance a ppears t o be l ow, t he r isk f or a s udden increase is high because of the relatively higher monoresistance to INH. It is essential to maintain high quality DOTS in the area to keep MDR low. Majority of respondents also had poor knowledge and several misconceptions about TB that needs to be addressed through continuous health education on cause, transmission, prevention, treatment and services available. Key w ords: Mycobacterium t uberculosis, S train di versity, D rug r esistance, KAP, Benishangul Gumuz region, Northwest Ethiopia