Provider Demographics
NPI:1710974696
Name:TESFAYE, TASSEW (MD)
Entity Type:Individual
Prefix:DR
First Name:TASSEW
Middle Name:
Last Name:TESFAYE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4958 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30083-4148
Mailing Address - Country:US
Mailing Address - Phone:404-809-2480
Mailing Address - Fax:404-809-2485
Practice Address - Street 1:4958 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30083-4148
Practice Address - Country:US
Practice Address - Phone:404-809-2480
Practice Address - Fax:404-809-2485
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-05
Last Update Date:2012-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA047542207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000870405CMedicaid
GA08BBVXRMedicare ID - Type Unspecified
511I080215Medicare UPIN
GA511I80215Medicare UPIN
GA511G700201Medicare PIN
GA202I089613Medicare UPIN
GA000870405CMedicaid