Healthcare Provider Details

I. General information

NPI: 1659986552
Provider Name (Legal Business Name): TADESSE G TADESSE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2020
Last Update Date: 09/09/2020
Certification Date: 08/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2648 GRANITE HILL CIR APT B
RICHMOND VA
23225-2068
US

IV. Provider business mailing address

2648 GRANITE HILL CIR APT B
RICHMOND VA
23225-2068
US

V. Phone/Fax

Practice location:
  • Phone: 202-641-2813
  • Fax:
Mailing address:
  • Phone: 202-641-2813
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code344600000X
TaxonomyTaxi
License NumberH135887
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: