Healthcare Provider Details

I. General information

NPI: 1013963297
Provider Name (Legal Business Name): BERHANE WUBSHET M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/26/2006
Last Update Date: 03/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9131 175TH ST
JAMAICA NY
11432-5517
US

IV. Provider business mailing address

3054 ANN ST
BALDWIN NY
11510-4501
US

V. Phone/Fax

Practice location:
  • Phone: 718-657-6363
  • Fax:
Mailing address:
  • Phone: 718-272-0977
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number195697
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: