Healthcare Provider Details

I. General information

NPI: 1760914089
Provider Name (Legal Business Name): ANTENEH TESEMA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2017
Last Update Date: 03/24/2023
Certification Date: 03/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 S UNION AVE
TACOMA WA
98405-1702
US

IV. Provider business mailing address

27835 242ND PL SE
MAPLE VALLEY WA
98038-3355
US

V. Phone/Fax

Practice location:
  • Phone: 253-459-6200
  • Fax:
Mailing address:
  • Phone: 408-605-3440
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number60563
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number61260762
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number61260762
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: