Provider Demographics
NPI:1316398043
Name:GEBRESENBET, KIRUBEL (DPM)
Entity Type:Individual
Prefix:
First Name:KIRUBEL
Middle Name:
Last Name:GEBRESENBET
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:331 FOREST CENTER DR APT 33006
Mailing Address - Street 2:
Mailing Address - City:KINGWOOD
Mailing Address - State:TX
Mailing Address - Zip Code:77339-5294
Mailing Address - Country:US
Mailing Address - Phone:619-342-6199
Mailing Address - Fax:
Practice Address - Street 1:2910 BROADWAY BLVD STE 212
Practice Address - Street 2:
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75041-3794
Practice Address - Country:US
Practice Address - Phone:619-342-6199
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-23
Last Update Date:2022-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2388213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2388OtherTEXAS DEPARTMENT OF LICENSING AND REGULATION
TXT62-2016OtherTEXAS STATE BOARD OF PODIATRIC MEDICAL EXAMINER