Provider Demographics
NPI:1558649467
Name:DEBELE, BRETT JACOB
Entity Type:Individual
Prefix:DR
First Name:BRETT
Middle Name:JACOB
Last Name:DEBELE
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 1:1304 W LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:FERGUS FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56537-4818
Mailing Address - Country:US
Mailing Address - Phone:218-998-0701
Mailing Address - Fax:
Practice Address - Street 1:1304 W LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:FERGUS FALLS
Practice Address - State:MN
Practice Address - Zip Code:56537-4818
Practice Address - Country:US
Practice Address - Phone:218-998-0701
Practice Address - Fax:218-998-2425
Is Sole Proprietor?:No
Enumeration Date:2011-07-26
Last Update Date:2011-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8791174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNC03152Medicare UPIN