Provider Demographics
NPI:1275587461
Name:TEFERRA, ETHIOPIA (MD)
Entity Type:Individual
Prefix:
First Name:ETHIOPIA
Middle Name:
Last Name:TEFERRA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:695 DUTCHESS TPKE
Mailing Address - Street 2:SUITE 105
Mailing Address - City:POUGHKEEPSIE
Mailing Address - State:NY
Mailing Address - Zip Code:12603-6442
Mailing Address - Country:US
Mailing Address - Phone:888-647-5979
Mailing Address - Fax:888-847-0818
Practice Address - Street 1:695 DUTCHESS TPKE
Practice Address - Street 2:SUITE 105
Practice Address - City:POUGHKEEPSIE
Practice Address - State:NY
Practice Address - Zip Code:12603-6442
Practice Address - Country:US
Practice Address - Phone:888-647-5979
Practice Address - Fax:888-847-0818
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-20
Last Update Date:2013-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD00524172085R0202X
NY2689002085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC2849OtherB/C B/S
MD475461100Medicaid
MDJ062OtherB/C B/S
MDKA80OtherB/C B/S
MDKA80OtherB/C B/S
MD435LA365Medicare ID - Type UnspecifiedLOCALITY/JURIS. CODE 02
MDCD4495Medicare ID - Type UnspecifiedRAILROAD MEDICARE
MD475461100Medicaid
DC2849OtherB/C B/S
MDCN2566Medicare ID - Type UnspecifiedRAILROAD MEDICARE