Basic Information
| Provider Information | |||||||||
| NPI: | 1316139066 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TESHOME | ||||||||
| FirstName: | KOKEB | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 710 MOUNT VERNON WAY | ||||||||
| Address2: | |||||||||
| City: | PETALUMA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949542512 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7075480667 | ||||||||
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| Practice Location | |||||||||
| Address1: | 400 N MCDOWELL BLVD | ||||||||
| Address2: | |||||||||
| City: | PETALUMA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949542339 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7077781111 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2007 | ||||||||
| LastUpdateDate: | 09/17/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | A93599 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | A93599 | CA | N | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 1316139066 | 01 | CA | NPI | OTHER |