Provider Demographics
NPI:1760482822
Name:TEDLA, FASIKA M (MD)
Entity Type:Individual
Prefix:
First Name:FASIKA
Middle Name:M
Last Name:TEDLA
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Gender:M
Credentials:MD
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Mailing Address - Street 1:1 GUSTAVE L LEVY PL # 1104
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10029-6504
Mailing Address - Country:US
Mailing Address - Phone:212-659-8086
Mailing Address - Fax:212-731-7220
Practice Address - Street 1:5 E 98TH ST FL 12
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029-6501
Practice Address - Country:US
Practice Address - Phone:212-659-8086
Practice Address - Fax:212-731-7220
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2019-11-07
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Provider Licenses
StateLicense IDTaxonomies
NY222336207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02668537Medicaid
NY02668537Medicaid
NY7X2381Medicare ID - Type Unspecified