Provider Demographics
NPI:1548021546
Name:DEGAGA, BENIYAM
Entity type:Individual
Prefix:
First Name:BENIYAM
Middle Name:
Last Name:DEGAGA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8111 STANFORD AVE SPC 134
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92841-4363
Mailing Address - Country:US
Mailing Address - Phone:424-386-5957
Mailing Address - Fax:
Practice Address - Street 1:6881 STANTON AVE
Practice Address - Street 2:
Practice Address - City:BUENA PARK
Practice Address - State:CA
Practice Address - Zip Code:90621-3648
Practice Address - Country:US
Practice Address - Phone:424-386-5957
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-17
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAF1371238172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver