Healthcare Provider Details

I. General information

NPI: 1124642889
Provider Name (Legal Business Name): DAWIT TESFAY HAILE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2020
Last Update Date: 06/26/2024
Certification Date: 06/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 COFFEE RD
MODESTO CA
95355-2803
US

IV. Provider business mailing address

3158 W MASTER ST
PHILADELPHIA PA
19121-4423
US

V. Phone/Fax

Practice location:
  • Phone: 209-526-4500
  • Fax:
Mailing address:
  • Phone: 202-520-6532
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberMT220191
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA195369
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: