Healthcare Provider Details

I. General information

NPI: 1720084783
Provider Name (Legal Business Name): YOHANNES GEBRE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2005
Last Update Date: 06/28/2023
Certification Date: 06/28/2023
Deactivation Date: 03/16/2006
Reactivation Date: 03/31/2006

III. Provider practice location address

1821 UNIVERSITY AVE W STE S206
SAINT PAUL MN
55104-2893
US

IV. Provider business mailing address

1821 UNIVERSITY AVE W STE S206
SAINT PAUL MN
55104-2893
US

V. Phone/Fax

Practice location:
  • Phone: 651-644-2273
  • Fax: 651-659-2273
Mailing address:
  • Phone: 651-644-2273
  • Fax: 651-659-2273

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number40937
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: