Provider Demographics
NPI:1063656593
Name:CHOMILO, NATHAN TSEBOH (MD)
Entity Type:Individual
Prefix:DR
First Name:NATHAN
Middle Name:TSEBOH
Last Name:CHOMILO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6000 EARLE BROWN DR
Mailing Address - Street 2:PEDIATRICS
Mailing Address - City:BROOKLYN CENTER
Mailing Address - State:MN
Mailing Address - Zip Code:55430-2506
Mailing Address - Country:US
Mailing Address - Phone:952-993-4909
Mailing Address - Fax:
Practice Address - Street 1:6000 EARLE BROWN DR
Practice Address - Street 2:PEDIATRICS
Practice Address - City:BROOKLYN CENTER
Practice Address - State:MN
Practice Address - Zip Code:55430-2506
Practice Address - Country:US
Practice Address - Phone:952-993-4909
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-28
Last Update Date:2016-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN53869208000000X
MN53689208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist