Provider Demographics
NPI:1700190964
Name:GUANGUL, BEREKET AZEZE (MD)
Entity Type:Individual
Prefix:DR
First Name:BEREKET
Middle Name:AZEZE
Last Name:GUANGUL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19801 N 59TH AVE UNIT 11073
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85318-5044
Mailing Address - Country:US
Mailing Address - Phone:480-228-3133
Mailing Address - Fax:
Practice Address - Street 1:18701 N 67TH AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-7100
Practice Address - Country:US
Practice Address - Phone:235-054-5906
Practice Address - Fax:623-933-3383
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-29
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ43772207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ605956Medicaid