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General NPI Number Information
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NPI Number | 1124642889
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Entity Type | Individual
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Provider Name | DAWIT TESFAY HAILE MD
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Gender | Male
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Dates
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Enumeration Date | 05/28/2020
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Last Update Date | 06/26/2024
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Provider Practice Location Address
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Address Line | 1700 COFFEE RD
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City | MODESTO
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State | CA
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Zip | 95355-2803
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Country | US
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Telephone | 209-526-4500
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Fax |
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Provider Business Mailing Address
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Address Line | 3158 W MASTER ST
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City | PHILADELPHIA
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State | PA
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Zip | 19121-4423
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Country | US
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Telephone | 202-520-6532
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number | MT220191
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License Number State | PA
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Taxonomy #2
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | A195369
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License Number State | CA
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