Healthcare Provider Details

I. General information

NPI: 1134488570
Provider Name (Legal Business Name): ADDISALEM TEDLA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2012
Last Update Date: 11/19/2022
Certification Date: 11/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 GALLOWS RD
FALLS CHURCH VA
22042
US

IV. Provider business mailing address

3300 GALLOWS RD
FALLS CHURCH VA
22042-3307
US

V. Phone/Fax

Practice location:
  • Phone: 703-776-6558
  • Fax:
Mailing address:
  • Phone: 703-776-6558
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101258985
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number0101258985
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: