Provider Demographics
NPI:1568926236
Name:AREDA, DEREJE DADI
Entity Type:Individual
Prefix:
First Name:DEREJE
Middle Name:DADI
Last Name:AREDA
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 1:360 MERIDIAN AVE APT 211
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95126-3460
Mailing Address - Country:US
Mailing Address - Phone:408-449-8182
Mailing Address - Fax:
Practice Address - Street 1:360 MERIDIAN AVE APT 211
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95126-3460
Practice Address - Country:US
Practice Address - Phone:408-449-8182
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-28
Last Update Date:2019-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD7101939172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver