Provider Demographics
NPI:1306002449
Name:TEFERA, KASSAHUN
Entity Type:Individual
Prefix:
First Name:KASSAHUN
Middle Name:
Last Name:TEFERA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3422 GEORGIA AVE NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20010-2592
Mailing Address - Country:US
Mailing Address - Phone:202-413-1092
Mailing Address - Fax:
Practice Address - Street 1:3422 GEORGIA AVE NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20001-4029
Practice Address - Country:US
Practice Address - Phone:202-413-1092
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-29
Last Update Date:2016-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL04213642246QC1000X, 291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
No246QC1000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, PathologyChemistry