Provider Demographics
NPI:1316553290
Name:GEBREHIWET, YOHANNES FESSEHA
Entity Type:Individual
Prefix:MR
First Name:YOHANNES
Middle Name:FESSEHA
Last Name:GEBREHIWET
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 1:2221 9TH AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94606-2613
Mailing Address - Country:US
Mailing Address - Phone:317-457-6690
Mailing Address - Fax:
Practice Address - Street 1:2221 9TH AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94606-2613
Practice Address - Country:US
Practice Address - Phone:317-457-6690
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-16
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAINT46728390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program