Provider Demographics
NPI:1477508331
Name:MARIAM, KIDISTI GHEBRE (OD)
Entity Type:Individual
Prefix:
First Name:KIDISTI
Middle Name:GHEBRE
Last Name:MARIAM
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:533 RIDGEVIEW CT
Mailing Address - Street 2:
Mailing Address - City:PLEASANT HILL
Mailing Address - State:CA
Mailing Address - Zip Code:94523-1023
Mailing Address - Country:US
Mailing Address - Phone:925-228-2585
Mailing Address - Fax:
Practice Address - Street 1:2201 VERNE ROBERTS CIR
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:CA
Practice Address - Zip Code:94509-7911
Practice Address - Country:US
Practice Address - Phone:925-757-1183
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11703T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist