Provider Demographics
NPI:1851357909
Name:HABTEMARIAM, MAKONNEN G (MD)
Entity Type:Individual
Prefix:DR
First Name:MAKONNEN
Middle Name:G
Last Name:HABTEMARIAM
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:P.O. BOX 11773
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85248
Mailing Address - Country:US
Mailing Address - Phone:480-907-7707
Mailing Address - Fax:480-907-7097
Practice Address - Street 1:1800 E VAN BUREN ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006-3742
Practice Address - Country:US
Practice Address - Phone:602-251-8100
Practice Address - Fax:480-907-7097
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-25
Last Update Date:2015-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ21618207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ21618OtherLICENSE
AZ331918Medicaid
AZ331918Medicaid
AZ331918-03Medicaid