Healthcare Provider Details

I. General information

NPI: 1215739701
Provider Name (Legal Business Name): DAGMAWI DEREJE WALE MD
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/25/2025
Last Update Date: 03/25/2025
Certification Date: 03/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2041 GEORGIA AVE NW
WASHINGTON DC
20060-0002
US

IV. Provider business mailing address

4676 SHUMATE DR
STONE MOUNTAIN GA
30083-6109
US

V. Phone/Fax

Practice location:
  • Phone: 202-865-6100
  • Fax:
Mailing address:
  • Phone: 404-418-2852
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: