Provider Demographics
NPI:1154524809
Name:TESFAYE, DEREJE (MD)
Entity type:Individual
Prefix:
First Name:DEREJE
Middle Name:
Last Name:TESFAYE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3135 STILES WAY
Mailing Address - Street 2:
Mailing Address - City:WEST FRIENDSHIP
Mailing Address - State:MD
Mailing Address - Zip Code:21794-9218
Mailing Address - Country:US
Mailing Address - Phone:410-872-8590
Mailing Address - Fax:410-872-0141
Practice Address - Street 1:6990 COLUMBIA GATEWAY DR
Practice Address - Street 2:SUITE 350
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21046-2953
Practice Address - Country:US
Practice Address - Phone:410-872-8590
Practice Address - Fax:410-872-0141
Is Sole Proprietor?:No
Enumeration Date:2007-06-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MDD0045693207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine