Healthcare Provider Details

I. General information

NPI: 1013145887
Provider Name (Legal Business Name): FISSEHA YITBAREK GHIDEY M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2009
Last Update Date: 03/07/2024
Certification Date: 03/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4509 GARFIELD ST
HYATTSVILLE MD
20781
US

IV. Provider business mailing address

4509 GARFIELD ST
HYATTSVILLE MD
20781-1963
US

V. Phone/Fax

Practice location:
  • Phone: 718-710-1813
  • Fax:
Mailing address:
  • Phone: 718-710-1813
  • Fax: 253-284-1881

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number0101251331
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number59991
License Number StateWI
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0101251331
License Number StateVA
# 5
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD041448
License Number StateDC
# 6
Primary TaxonomyN
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number59991
License Number StateWI
# 7
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberD79362
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: