Provider Demographics
NPI:1386070159
Name:TEKETEL, TEWODROS WOLDEMARIAM (MD)
Entity type:Individual
Prefix:DR
First Name:TEWODROS
Middle Name:WOLDEMARIAM
Last Name:TEKETEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:TEWODROS
Other - Middle Name:W
Other - Last Name:TEKETEL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:25311 KINGSLAND BLVD STE 190
Mailing Address - Street 2:
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77494-7349
Mailing Address - Country:US
Mailing Address - Phone:832-447-6454
Mailing Address - Fax:
Practice Address - Street 1:25311 KINGSLAND BLVD STE 190
Practice Address - Street 2:
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77494-7349
Practice Address - Country:US
Practice Address - Phone:832-447-6454
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-24
Last Update Date:2021-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ9058207R00000X, 208D00000X
CAA128719207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program