=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679787386
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | FIKADU GEBREYES TEKLEYES MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/10/2007
-----------------------------------------------------
Last Update Date | 03/19/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1320 W MAIN ST
-----------------------------------------------------
City | NEWARK
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43055
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 220-564-7750
-----------------------------------------------------
Fax | 220-564-7751
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1320 W MAIN ST
-----------------------------------------------------
City | NEWARK
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43055
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 220-564-7750
-----------------------------------------------------
Fax | 220-564-7751
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RC0000X
-----------------------------------------------------
Taxonomy Name | Cardiovascular Disease Physician
-----------------------------------------------------
License Number | 35.129008
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------