Healthcare Provider Details

I. General information

NPI: 1245852284
Provider Name (Legal Business Name): DEREJE SEYOUM LEGESSE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/13/2020
Last Update Date: 09/10/2024
Certification Date: 09/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

745 POPLAR RD
NEWNAN GA
30265-1618
US

IV. Provider business mailing address

3041 CEDAR CREEK PKWY
DECATUR GA
30033-4415
US

V. Phone/Fax

Practice location:
  • Phone: 770-400-2353
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number99350
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number99350
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: