Provider Demographics
NPI:1821615782
Name:DEREJE, ABRAHAM
Entity Type:Individual
Prefix:
First Name:ABRAHAM
Middle Name:
Last Name:DEREJE
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 1:483 SUNNYCLIFF PL
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45459-4344
Mailing Address - Country:US
Mailing Address - Phone:937-818-9948
Mailing Address - Fax:
Practice Address - Street 1:483 SUNNYCLIFF PL
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45459-4344
Practice Address - Country:US
Practice Address - Phone:937-818-9948
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-26
Last Update Date:2020-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program