Healthcare Provider Details

I. General information

NPI: 1033031851
Provider Name (Legal Business Name): MIKIYAS GIFAWOSEN TEFERI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2026
Last Update Date: 07/27/2026
Certification Date: 07/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3780 EISENHOWER PKWY
MACON GA
31206-0800
US

IV. Provider business mailing address

867 ORANGE TER
MACON GA
31201-2149
US

V. Phone/Fax

Practice location:
  • Phone: 478-442-0584
  • Fax:
Mailing address:
  • Phone: 971-837-5435
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number114052
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: