Provider Demographics
NPI:1003063918
Name:AKLILU, EPHRAIM W
Entity Type:Individual
Prefix:DR
First Name:EPHRAIM
Middle Name:W
Last Name:AKLILU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58 WEST PORTAL AVENUE # 106
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94127-2187
Mailing Address - Country:US
Mailing Address - Phone:510-914-6903
Mailing Address - Fax:
Practice Address - Street 1:58 W PORTAL AVE # 106
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94127-1304
Practice Address - Country:US
Practice Address - Phone:510-914-6903
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-21
Last Update Date:2012-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA55180122300000X
CA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No122300000XDental ProvidersDentist