Provider Demographics
NPI:1689766065
Name:TEKLEHAIMANOT, DAWIT (DO)
Entity Type:Individual
Prefix:
First Name:DAWIT
Middle Name:
Last Name:TEKLEHAIMANOT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4261 SILVERLEAF DR
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-7484
Mailing Address - Country:US
Mailing Address - Phone:248-552-9233
Mailing Address - Fax:248-552-9244
Practice Address - Street 1:PHYSICAL MEDICINE AND REHABILATION AND PAIN CONSULTANT
Practice Address - Street 2:17117 WEST NINE MILE ROAD SUITE 1331
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075
Practice Address - Country:US
Practice Address - Phone:248-552-9233
Practice Address - Fax:248-552-9244
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101011761174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
0P29260Medicare ID - Type Unspecified
G38510Medicare UPIN