Provider Demographics
NPI:1043547938
Name:MAKONNEN G HABTEMARIAM PLLC
Entity Type:Organization
Organization Name:MAKONNEN G HABTEMARIAM PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:MAKONNEN
Authorized Official - Middle Name:G
Authorized Official - Last Name:HABTEMARIAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-907-7707
Mailing Address - Street 1:PO BOX 11773
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85248-0013
Mailing Address - Country:US
Mailing Address - Phone:480-907-7707
Mailing Address - Fax:480-907-7097
Practice Address - Street 1:1800 E VAN BUREN ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006-3742
Practice Address - Country:US
Practice Address - Phone:480-907-7707
Practice Address - Fax:480-907-7097
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-12
Last Update Date:2015-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ331918Medicaid
AZZ134934Medicare UPIN