Provider Demographics
NPI:1760793897
Name:DERERIE, WONDWOSSEN YILMA (MD)
Entity Type:Individual
Prefix:DR
First Name:WONDWOSSEN
Middle Name:YILMA
Last Name:DERERIE
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 1:5102 WINDBREAK DR
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22407-9323
Mailing Address - Country:US
Mailing Address - Phone:857-998-8902
Mailing Address - Fax:
Practice Address - Street 1:2800 GODWIN BLVD
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434-8038
Practice Address - Country:US
Practice Address - Phone:757-934-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-23
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.130138207R00000X
VA0101254930207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine