Healthcare Provider Details

I. General information

NPI: 1598794646
Provider Name (Legal Business Name): ASHEBIR GEBRU WOLDEABEZGI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2006
Last Update Date: 10/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11637 TERRACE DR SUITE 103
WALDORF MD
20602-3706
US

IV. Provider business mailing address

11637 TERRACE DR SUITE 103
WALDORF MD
20602-3706
US

V. Phone/Fax

Practice location:
  • Phone: 301-374-9725
  • Fax: 301-374-9181
Mailing address:
  • Phone: 301-374-9725
  • Fax: 301-374-9181

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberD0062596
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0101240403
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD035472
License Number StateDC
# 4
Primary TaxonomyN
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License NumberD0062596
License Number StateMD
# 5
Primary TaxonomyN
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number0101240403
License Number StateVA
# 6
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License NumberMD035472
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: