Provider Demographics
NPI:1558472878
Name:GEDAMU, TEWODROS (OD)
Entity Type:Individual
Prefix:DR
First Name:TEWODROS
Middle Name:
Last Name:GEDAMU
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11654 PLAZA AMERICA DR
Mailing Address - Street 2:SUITE 194
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20190-4700
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:703-352-8709
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2014-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA 1661152W00000X
VA0618001068152W00000X
DCOP1000039152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA236772TGZVMedicare PIN