Provider Demographics
NPI:1962516179
Name:AYALEW, KASSA (MD)
Entity type:Individual
Prefix:DR
First Name:KASSA
Middle Name:
Last Name:AYALEW
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 1:4921 SEMINARY RD
Mailing Address - Street 2:SUITE 115
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22311-1838
Mailing Address - Country:US
Mailing Address - Phone:703-778-9998
Mailing Address - Fax:
Practice Address - Street 1:4921 SEMINARY RD
Practice Address - Street 2:SUITE 115
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22311-1838
Practice Address - Country:US
Practice Address - Phone:703-778-9998
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2023-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101233921208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010140129Medicaid