Provider Demographics
NPI:1023033065
Name:TESFAYE, DANIEL (MD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:
Last Name:TESFAYE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 542
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30012
Mailing Address - Country:US
Mailing Address - Phone:770-274-3378
Mailing Address - Fax:
Practice Address - Street 1:1368 WELLBROOK CIR NE
Practice Address - Street 2:STE A
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30012-3980
Practice Address - Country:US
Practice Address - Phone:770-274-3378
Practice Address - Fax:770-274-3378
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2019-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA676142084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89126GJMedicaid
NC89126GJMedicaid
NC2280364BMedicare PIN