=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154524809
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DEREJE TESFAYE M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/08/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6990 COLUMBIA GATEWAY DR SUITE 350
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21046-2953
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-872-8590
-----------------------------------------------------
Fax | 410-872-0141
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3135 STILES WAY
-----------------------------------------------------
City | WEST FRIENDSHIP
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21794-9218
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-872-8590
-----------------------------------------------------
Fax | 410-872-0141
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | D0045693
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------