Provider Demographics
NPI:1750196556
Name:SEYOUM, ANDARGACHEW B
Entity type:Individual
Prefix:
First Name:ANDARGACHEW
Middle Name:B
Last Name:SEYOUM
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 1:2302 PEACH OAK XING
Mailing Address - Street 2:
Mailing Address - City:MANVEL
Mailing Address - State:TX
Mailing Address - Zip Code:77578-4157
Mailing Address - Country:US
Mailing Address - Phone:702-684-0083
Mailing Address - Fax:
Practice Address - Street 1:2302 PEACH OAK XING
Practice Address - Street 2:
Practice Address - City:MANVEL
Practice Address - State:TX
Practice Address - Zip Code:77578-4157
Practice Address - Country:US
Practice Address - Phone:702-684-0083
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-10
Last Update Date:2025-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0805889178172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver