Healthcare Provider Details

I. General information

NPI: 1962792499
Provider Name (Legal Business Name): DEREJE FIKREMARIAM MOTI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2011
Last Update Date: 04/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 N HIGLEY RD
GILBERT AZ
85234-1604
US

IV. Provider business mailing address

1900 N HIGLEY RD ATTN: HOSPITALISTS
GILBERT AZ
85234-1604
US

V. Phone/Fax

Practice location:
  • Phone: 480-543-2034
  • Fax: 480-543-2034
Mailing address:
  • Phone: 480-543-2034
  • Fax: 480-543-2647

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number49398
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number9727248-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: