Provider Demographics
NPI:1417646621
Name:MAMO, SURAFEL
Entity Type:Individual
Prefix:
First Name:SURAFEL
Middle Name:
Last Name:MAMO
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 1:1001 S HAVANA ST APT 212
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80012-2904
Mailing Address - Country:US
Mailing Address - Phone:720-614-2261
Mailing Address - Fax:
Practice Address - Street 1:630 S DAYTON ST APT 15-109
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80247-1340
Practice Address - Country:US
Practice Address - Phone:720-614-2261
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-03
Last Update Date:2023-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO347E00000X
347E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347E00000XTransportation ServicesTransportation Broker