Provider Demographics
NPI:1487026746
Name:GEBREWOLD, HABTOM HADUSH
Entity Type:Individual
Prefix:
First Name:HABTOM
Middle Name:HADUSH
Last Name:GEBREWOLD
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 1:12526 E CORNELL AVE UNIT 102
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80014
Mailing Address - Country:US
Mailing Address - Phone:702-727-9372
Mailing Address - Fax:
Practice Address - Street 1:12526 E CORNELL AVE UNIT 102
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80014
Practice Address - Country:US
Practice Address - Phone:702-727-9372
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-27
Last Update Date:2015-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO20151667853172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver