Healthcare Provider Details

I. General information

NPI: 1780145847
Provider Name (Legal Business Name): KIRUBEL WOLDEMICHAEL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2019
Last Update Date: 07/11/2023
Certification Date: 07/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 GLADE CT APT 8
KRONENWETTER WI
54455-7335
US

IV. Provider business mailing address

825 GLADE CT APT 8
KRONENWETTER WI
54455-7335
US

V. Phone/Fax

Practice location:
  • Phone: 571-426-9405
  • Fax:
Mailing address:
  • Phone: 571-426-9405
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number76277-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: