Provider Demographics
NPI:1033489216
Name:TESFAYE D FANTA MD PLLC
Entity Type:Organization
Organization Name:TESFAYE D FANTA MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TESFAYE
Authorized Official - Middle Name:DEMISSIE
Authorized Official - Last Name:FANTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:336-342-9564
Mailing Address - Street 1:910 W HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:REIDSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27320-3324
Mailing Address - Country:US
Mailing Address - Phone:336-342-9564
Mailing Address - Fax:336-349-9723
Practice Address - Street 1:910 W HARRISON ST
Practice Address - Street 2:
Practice Address - City:REIDSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27320-3324
Practice Address - Country:US
Practice Address - Phone:336-342-9564
Practice Address - Fax:336-349-9723
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-05
Last Update Date:2012-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200900231207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891066AMedicaid
NC1522XOtherBCBS
NC1066AOtherBCBS
NC5911977Medicaid
NC2240802BMedicare PIN
NC2073533Medicare PIN