Provider Demographics
NPI:1952413627
Name:HAILU, TEGEST
Entity Type:Individual
Prefix:
First Name:TEGEST
Middle Name:
Last Name:HAILU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7011 N HOWARD ST
Mailing Address - Street 2:STE 202
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-2955
Mailing Address - Country:US
Mailing Address - Phone:559-907-7852
Mailing Address - Fax:
Practice Address - Street 1:7011 N HOWARD ST
Practice Address - Street 2:STE 202
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-2955
Practice Address - Country:US
Practice Address - Phone:559-438-0555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2016-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA60221207Q00000X, 207RH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A602210Medicaid
CA00A602210Medicaid
CAG47610Medicare UPIN