Provider Demographics
NPI:1538690631
Name:TESFAMICHAEL, BEREKET YESHAK
Entity Type:Individual
Prefix:
First Name:BEREKET
Middle Name:YESHAK
Last Name:TESFAMICHAEL
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 1:3923 S QUEMOY WAY
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80018-3138
Mailing Address - Country:US
Mailing Address - Phone:720-609-9223
Mailing Address - Fax:
Practice Address - Street 1:3923 S QUEMOY WAY
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80018-3138
Practice Address - Country:US
Practice Address - Phone:720-609-9223
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-21
Last Update Date:2017-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO963470820172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver