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General NPI Number Information
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NPI Number | 1033489216
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Entity Type | Organization
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Legal Business Name | TESFAYE D FANTA MD PLLC
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Dates
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Enumeration Date | 01/05/2012
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Last Update Date | 01/05/2012
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Provider Practice Location Address
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Address Line | 910 W HARRISON ST
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City | REIDSVILLE
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State | NC
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Zip | 27320-3324
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Country | US
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Telephone | 336-342-9564
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Fax | 336-349-9723
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Provider Business Mailing Address
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Address Line | 910 W HARRISON ST
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City | REIDSVILLE
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State | NC
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Zip | 27320-3324
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Country | US
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Telephone | 336-342-9564
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Fax | 336-349-9723
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Authorized Official
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Title or Position | OWNER
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Name | DR. TESFAYE DEMISSIE FANTA
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Credential | MD
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Telephone | 336-342-9564
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RE0101X
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Taxonomy Name | Endocrinology, Diabetes & Metabolism Physician
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License Number | 200900231
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License Number State | NC
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