Healthcare Provider Details

I. General information

NPI: 1811758378
Provider Name (Legal Business Name): MR. GIRMA B GEBREMARIAM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/22/2024
Last Update Date: 01/22/2024
Certification Date: 01/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6602 FALCON ST
ROWLETT TX
75089-2901
US

IV. Provider business mailing address

6602 FALCON ST
ROWLETT TX
75089-2901
US

V. Phone/Fax

Practice location:
  • Phone: 404-988-0557
  • Fax:
Mailing address:
  • Phone: 404-988-0557
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number45236014
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: