Provider Demographics
NPI:1689764128
Name:ZELALEM TESDAY MD A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:ZELALEM TESDAY MD A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ZELALEM
Authorized Official - Middle Name:
Authorized Official - Last Name:TESFAY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-582-9330
Mailing Address - Street 1:3111 E FLORENCE AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90255-5829
Mailing Address - Country:US
Mailing Address - Phone:323-582-9330
Mailing Address - Fax:323-582-8903
Practice Address - Street 1:3111 E FLORENCE AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON PARK
Practice Address - State:CA
Practice Address - Zip Code:90255-5829
Practice Address - Country:US
Practice Address - Phone:323-582-9330
Practice Address - Fax:323-582-8903
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-13
Last Update Date:2009-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG76854207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G768544Medicaid
CA05D0985404OtherCLIA #