Provider Demographics
NPI:1962461509
Name:TEZERA, SISSAY (DC)
Entity Type:Individual
Prefix:
First Name:SISSAY
Middle Name:
Last Name:TEZERA
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18551 W 10 MILE RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-2663
Mailing Address - Country:US
Mailing Address - Phone:248-443-1995
Mailing Address - Fax:248-443-5573
Practice Address - Street 1:18551 W 10 MILE RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-2663
Practice Address - Country:US
Practice Address - Phone:248-443-1995
Practice Address - Fax:248-443-5573
Is Sole Proprietor?:No
Enumeration Date:2006-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIST006145111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI95OF373730OtherBCBS
MIST006145OtherLICENSE
MIU62411Medicare UPIN
MIOM59750010Medicare ID - Type Unspecified