Provider Demographics
NPI:1215787395
Name:MAMO, GETAHUN
Entity type:Individual
Prefix:
First Name:GETAHUN
Middle Name:
Last Name:MAMO
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 1:906 PARKSTONE DR
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30083-3518
Mailing Address - Country:US
Mailing Address - Phone:404-751-7829
Mailing Address - Fax:
Practice Address - Street 1:906 PARKSTONE DR
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30083-3518
Practice Address - Country:US
Practice Address - Phone:404-751-7829
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-25
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver