Healthcare Provider Details

I. General information

NPI: 1760482822
Provider Name (Legal Business Name): FASIKA M TEDLA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2005
Last Update Date: 11/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 E 98TH ST FL 12
NEW YORK NY
10029-6501
US

IV. Provider business mailing address

1 GUSTAVE L LEVY PL # 1104
NEW YORK NY
10029-6504
US

V. Phone/Fax

Practice location:
  • Phone: 212-659-8086
  • Fax: 212-731-7220
Mailing address:
  • Phone: 212-659-8086
  • Fax: 212-731-7220

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number222336
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: