Healthcare Provider Details

I. General information

NPI: 1396662193
Provider Name (Legal Business Name): MEDHANE TESFAMICHAEL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2026
Last Update Date: 07/01/2026
Certification Date: 07/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

733 S FREDERICK AVE
GAITHERSBURG MD
20877-4118
US

IV. Provider business mailing address

12910 GRIFFIN CIR
CLARKSBURG MD
20871-9245
US

V. Phone/Fax

Practice location:
  • Phone: 130-186-9070
  • Fax:
Mailing address:
  • Phone: 240-722-9056
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2471C3402X
TaxonomyRadiography Radiologic Technologist
License NumberR0014611
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: