Healthcare Provider Details

I. General information

NPI: 1528715968
Provider Name (Legal Business Name): LETERA KASSAHUN TEREFASA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2022
Last Update Date: 09/02/2026
Certification Date: 09/02/2026
Deactivation Date: 03/27/2025
Reactivation Date: 04/08/2025

III. Provider practice location address

1601 W 40TH AVE
PINE BLUFF AR
71603-6069
US

IV. Provider business mailing address

1601 W 40TH AVE
PINE BLUFF AR
71603-6069
US

V. Phone/Fax

Practice location:
  • Phone: 870-541-6010
  • Fax: 870-541-6009
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberE20979
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberE20979
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: