Provider Demographics
NPI:1568713600
Name:LEGASION TEKLE, MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:LEGASION TEKLE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:MICHAEL
Other - Middle Name:
Other - Last Name:LEGASION
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:7250 PARKWAY DR
Mailing Address - Street 2:STE 500
Mailing Address - City:HANOVER
Mailing Address - State:MD
Mailing Address - Zip Code:21076-1343
Mailing Address - Country:US
Mailing Address - Phone:202-615-1165
Mailing Address - Fax:
Practice Address - Street 1:1545 ATLANTIC AVENUE
Practice Address - Street 2:INTERFAITH MEDICAL CENTER,
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11213
Practice Address - Country:US
Practice Address - Phone:202-615-1165
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-28
Last Update Date:2017-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MDD79466208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program