Healthcare Provider Details

I. General information

NPI: 1922481746
Provider Name (Legal Business Name): ETSEGENET F. TIZAZU M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2015
Last Update Date: 03/30/2021
Certification Date: 03/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 HYGEIA DR STE 1420
NEWARK DE
19713-2049
US

IV. Provider business mailing address

200 HYGEIA DR STE 1420
NEWARK DE
19713-2049
US

V. Phone/Fax

Practice location:
  • Phone: 302-623-3017
  • Fax: 302-266-9960
Mailing address:
  • Phone: 302-623-3017
  • Fax: 302-266-9960

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberMD467286
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberC1-0024150
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: