Healthcare Provider Details

I. General information

NPI: 1922446632
Provider Name (Legal Business Name): NEBIYOU WONDIMAGEGNEHU MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2013
Last Update Date: 09/13/2022
Certification Date: 09/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4309 102ND ST
LUBBOCK TX
79423-5708
US

IV. Provider business mailing address

5219 CITY BANK PKWY STE 35
LUBBOCK TX
79407-3545
US

V. Phone/Fax

Practice location:
  • Phone: 806-761-0747
  • Fax: 806-761-0751
Mailing address:
  • Phone: 806-761-0334
  • Fax: 806-785-0872

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberQ7305
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberQ7305
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: