Healthcare Provider Details

I. General information

NPI: 1518272228
Provider Name (Legal Business Name): YOHANNES TESFALEM GEBREKIDAN M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2010
Last Update Date: 01/31/2022
Certification Date: 01/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2041 GEORGIA AVD NW # 1
WASHINGTON DC
20060-0001
US

IV. Provider business mailing address

3139 UNIVERSITY BLVD W APT 2 C2
KENSINGTON MD
20895-1814
US

V. Phone/Fax

Practice location:
  • Phone: 716-348-2593
  • Fax:
Mailing address:
  • Phone: 716-348-2593
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC0004378
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberD91358
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: