Provider Demographics
NPI:1588729065
Name:WOLDEMICHAEL, GHEBRU W (MD)
Entity type:Individual
Prefix:DR
First Name:GHEBRU
Middle Name:W
Last Name:WOLDEMICHAEL
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 1:2851 S AVE B
Mailing Address - Street 2:SUITE 2601
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85364-7726
Mailing Address - Country:US
Mailing Address - Phone:928-317-9562
Mailing Address - Fax:928-726-1588
Practice Address - Street 1:2851 S AVE B
Practice Address - Street 2:SUITE 2601
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-7726
Practice Address - Country:US
Practice Address - Phone:928-317-9562
Practice Address - Fax:928-726-1588
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-26
Last Update Date:2011-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ31647174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ0004053776OtherAETNA
AZ836025Medicaid
AZAZ0735990OtherBCBS
AZAZ0735990OtherBCBS
AZ75653Medicare ID - Type Unspecified