Provider Demographics
NPI:1255367769
Name:GEBRE, WONDWOSSEN
Entity type:Individual
Prefix:
First Name:WONDWOSSEN
Middle Name:
Last Name:GEBRE
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 1:2201 HEMPSTEAD TPKE
Mailing Address - Street 2:
Mailing Address - City:EAST MEADOW
Mailing Address - State:NY
Mailing Address - Zip Code:11554-1859
Mailing Address - Country:US
Mailing Address - Phone:516-572-3201
Mailing Address - Fax:
Practice Address - Street 1:2201 HEMPSTEAD TPKE
Practice Address - Street 2:
Practice Address - City:EAST MEADOW
Practice Address - State:NY
Practice Address - Zip Code:11554-1859
Practice Address - Country:US
Practice Address - Phone:516-572-3201
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-25
Last Update Date:2008-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY213832207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
I03475Medicare UPIN
NY56R131Medicare PIN