Provider Demographics
NPI:1750563623
Name:TEREFE-GIFAWOSSEN, EJEGAYEHU (MD)
Entity type:Individual
Prefix:
First Name:EJEGAYEHU
Middle Name:
Last Name:TEREFE-GIFAWOSSEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:EJEGAYEHU
Other - Middle Name:
Other - Last Name:GIFAWOSSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:6626 E 75TH ST
Mailing Address - Street 2:SUITE 500
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2890
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3500 S LAFOUNTAIN ST
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46902-3803
Practice Address - Country:US
Practice Address - Phone:765-865-8630
Practice Address - Fax:765-864-5901
Is Sole Proprietor?:No
Enumeration Date:2007-12-03
Last Update Date:2014-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01068519207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200996560Medicaid
INP01270943OtherRR MEDICARE
INP00905153OtherRAILROAD MEDICARE PTAN
ININ1663028Medicare PIN
INM400019543Medicare PIN