Healthcare Provider Details

I. General information

NPI: 1972438836
Provider Name (Legal Business Name): WONDIMAGEGN TIBEBU TILAHUN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2026
Last Update Date: 06/15/2026
Certification Date: 06/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1199 PRINCE AVE
ATHENS GA
30606-2797
US

IV. Provider business mailing address

888 HORIZON BLVD APT 2933
ATHENS GA
30606-1247
US

V. Phone/Fax

Practice location:
  • Phone: 706-475-7000
  • Fax:
Mailing address:
  • Phone: 410-716-6030
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: