Provider Demographics
NPI:1366412751
Name:ADDISSE, TEWODROS D (MD)
Entity type:Individual
Prefix:DR
First Name:TEWODROS
Middle Name:D
Last Name:ADDISSE
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 1:1500 SW 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:TOPEKA
Mailing Address - State:KS
Mailing Address - Zip Code:66604-1301
Mailing Address - Country:US
Mailing Address - Phone:785-354-5242
Mailing Address - Fax:
Practice Address - Street 1:1500 SW 10TH AVE
Practice Address - Street 2:
Practice Address - City:TOPEKA
Practice Address - State:KS
Practice Address - Zip Code:66604-1301
Practice Address - Country:US
Practice Address - Phone:785-354-5242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2024-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-28657207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS067327OtherMEDICARE PTAN
KS100380470DMedicaid
KS100380470DMedicaid