Healthcare Provider Details

I. General information

NPI: 1699712117
Provider Name (Legal Business Name): NEGASH AYELE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 01/24/2022
Certification Date: 01/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4320 SEMINARY RD
ALEXANDRIA VA
22304-1535
US

IV. Provider business mailing address

2876 GUARDIAN LN
VIRGINIA BEACH VA
23452-7327
US

V. Phone/Fax

Practice location:
  • Phone: 703-504-3000
  • Fax: 703-504-7733
Mailing address:
  • Phone: 757-463-5240
  • Fax: 757-463-6572

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0101229247
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: