Provider Demographics
NPI:1114101425
Name:TEWODROS GEDAMU, O.D. & ASSOCIATES, LLC
Entity Type:Organization
Organization Name:TEWODROS GEDAMU, O.D. & ASSOCIATES, LLC
Other - Org Name:DR. TEWODROS GEDAMU & ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:TEWODROS
Authorized Official - Middle Name:
Authorized Official - Last Name:GEDAMU
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:703-591-9377
Mailing Address - Street 1:9435 LORTON MARKET ST
Mailing Address - Street 2:SUITE 753
Mailing Address - City:LORTON
Mailing Address - State:VA
Mailing Address - Zip Code:22079-1963
Mailing Address - Country:US
Mailing Address - Phone:703-591-9377
Mailing Address - Fax:703-352-8709
Practice Address - Street 1:11784 LEE JACKSON MEMORIAL HIGHWAY
Practice Address - Street 2:FAIROAKS MALL LOWER LEVEL
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033
Practice Address - Country:US
Practice Address - Phone:703-591-9377
Practice Address - Fax:703-591-9377
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-21
Last Update Date:2009-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA06180001068152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty