Provider Demographics
NPI:1982750360
Name:GEBREZGI, SEBHATU TEWOLDE (MD)
Entity Type:Individual
Prefix:
First Name:SEBHATU
Middle Name:TEWOLDE
Last Name:GEBREZGI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9408 FLATLANDS AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11236
Mailing Address - Country:US
Mailing Address - Phone:718-272-0977
Mailing Address - Fax:718-272-1088
Practice Address - Street 1:9408 FLATLANDS AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11236
Practice Address - Country:US
Practice Address - Phone:718-272-0977
Practice Address - Fax:718-272-1088
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-26
Last Update Date:2012-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY196278207R00000X, 173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01545362Medicaid
F96787Medicare UPIN
NY01545362Medicaid