Provider Demographics
NPI:1235982778
Name:DERBEW, JERUSALEM DESALGN
Entity type:Individual
Prefix:
First Name:JERUSALEM
Middle Name:DESALGN
Last Name:DERBEW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JERUSALEM
Other - Middle Name:DESALEGN
Other - Last Name:DERBEW
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:8250 MEADOW RD # 6314
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75231-3745
Mailing Address - Country:US
Mailing Address - Phone:214-791-0536
Mailing Address - Fax:
Practice Address - Street 1:12225 GREENVILLE AVE STE 703
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75243-9362
Practice Address - Country:US
Practice Address - Phone:469-748-7775
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-05
Last Update Date:2024-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX99-1864371172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver