Provider Demographics
NPI:1285834192
Name:TEDLA, TESFAMARIAM MEBRAHTOM (MD)
Entity Type:Individual
Prefix:DR
First Name:TESFAMARIAM
Middle Name:MEBRAHTOM
Last Name:TEDLA
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 1:10223 POLIZZOTTO LN
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:TX
Mailing Address - Zip Code:77407-2698
Mailing Address - Country:US
Mailing Address - Phone:276-698-1595
Mailing Address - Fax:
Practice Address - Street 1:12345 KATY FWY
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77079-1503
Practice Address - Country:US
Practice Address - Phone:281-679-5600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-19
Last Update Date:2016-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101241974207Q00000X
MDD0066250207Q00000X
TXN4791207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine