Provider Demographics
NPI:1023858370
Name:ASSEFA, HAMELMAL BERHANU
Entity type:Individual
Prefix:MR
First Name:HAMELMAL
Middle Name:BERHANU
Last Name:ASSEFA
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 1:1621 S JUPITER RD
Mailing Address - Street 2:
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75042-7792
Mailing Address - Country:US
Mailing Address - Phone:469-867-4279
Mailing Address - Fax:
Practice Address - Street 1:1800 BARNES BRIDGE RD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75228-2123
Practice Address - Country:US
Practice Address - Phone:214-580-6184
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-24
Last Update Date:2024-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX43461293172A00000X
172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver