Healthcare Provider Details

I. General information

NPI: 1508249764
Provider Name (Legal Business Name): ERMIAS GEBREGZIABHER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2015
Last Update Date: 07/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2625 COFFEE RD SUITE S
MODESTO CA
95355-2050
US

IV. Provider business mailing address

2625 COFFEE RD SUITE S
MODESTO CA
95355-2050
US

V. Phone/Fax

Practice location:
  • Phone: 209-577-1200
  • Fax: 209-579-9573
Mailing address:
  • Phone: 209-577-1200
  • Fax: 209-579-9573

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246QH0600X
TaxonomyHistology Specialist/Technologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: