Healthcare Provider Details

I. General information

NPI: 1255918124
Provider Name (Legal Business Name): EDOM ENDALE GENEMO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2021
Last Update Date: 07/15/2024
Certification Date: 06/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8316 ARLINGTON BLVD STE 300
FAIRFAX VA
22031-5216
US

IV. Provider business mailing address

8316 ARLINGTON BLVD STE 300
FAIRFAX VA
22031-5216
US

V. Phone/Fax

Practice location:
  • Phone: 703-468-4195
  • Fax: 703-280-9350
Mailing address:
  • Phone: 703-573-2432
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101283017
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: