Basic Information
| Provider Information | |||||||||
| NPI: | 1851357909 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HABTEMARIAM | ||||||||
| FirstName: | MAKONNEN | ||||||||
| MiddleName: | G. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 11773 | ||||||||
| Address2: | |||||||||
| City: | CHANDLER | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85248 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4809077707 | ||||||||
| FaxNumber: | 4809077097 | ||||||||
| Practice Location | |||||||||
| Address1: | 1800 E VAN BUREN ST | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850063742 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022518100 | ||||||||
| FaxNumber: | 4809077097 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2006 | ||||||||
| LastUpdateDate: | 04/24/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 21618 | AZ | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | 21618 | AZ | N | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 21618 | 01 | AZ | LICENSE | OTHER | 331918 | 05 | AZ | MEDICAID |