Provider Demographics
NPI:1407451693
Name:GHEBREHIWOT, DAWIT
Entity Type:Individual
Prefix:
First Name:DAWIT
Middle Name:
Last Name:GHEBREHIWOT
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 1:14501 MONTFORT DR APT 310
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75254-8549
Mailing Address - Country:US
Mailing Address - Phone:216-925-7302
Mailing Address - Fax:
Practice Address - Street 1:9390 FOREST LN
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75243-4214
Practice Address - Country:US
Practice Address - Phone:214-341-3600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-03
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX59613183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist