Provider Demographics
NPI:1275747891
Name:TADDESSE, ABAY TASSEW (MD)
Entity Type:Individual
Prefix:
First Name:ABAY
Middle Name:TASSEW
Last Name:TADDESSE
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 1:4001 COLISEUM DR STE 310
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23666-6257
Mailing Address - Country:US
Mailing Address - Phone:757-827-2115
Mailing Address - Fax:757-510-9383
Practice Address - Street 1:4001 COLISEUM DR STE 310
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-6257
Practice Address - Country:US
Practice Address - Phone:757-827-2115
Practice Address - Fax:757-510-9383
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2021-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35097654207RE0101X
MI4301095243390200000X
VA0101257190207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1275747891Medicaid
VA1275747891Medicaid