Healthcare Provider Details

I. General information

NPI: 1306334644
Provider Name (Legal Business Name): YILMA KEBEDE KEBELO MD, DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2018
Last Update Date: 10/07/2024
Certification Date: 10/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2421 W 21ST ST STE B
CLOVIS NM
88101-2006
US

IV. Provider business mailing address

PO BOX 26666
ALBUQUERQUE NM
87125-6666
US

V. Phone/Fax

Practice location:
  • Phone: 575-769-7577
  • Fax:
Mailing address:
  • Phone: 505-923-5361
  • Fax: 505-923-5354

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPOD2024-0010
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberE5786
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: