Provider Demographics
NPI:1871886622
Name:GHEREZGHIHER, AWET T (MD)
Entity type:Individual
Prefix:
First Name:AWET
Middle Name:T
Last Name:GHEREZGHIHER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 W TERRELL AVE STE 400
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-2829
Mailing Address - Country:US
Mailing Address - Phone:817-250-7247
Mailing Address - Fax:
Practice Address - Street 1:1300 W TERRELL AVE STE 400
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2829
Practice Address - Country:US
Practice Address - Phone:817-250-7247
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-25
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ52544208800000X
PAMT199237208800000X
TXU8059208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ155048Medicaid
2189942Medicare UPIN