Provider Demographics
NPI:1972590743
Name:ANBESSIE, TEDLA
Entity Type:Individual
Prefix:DR
First Name:TEDLA
Middle Name:
Last Name:ANBESSIE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4600 KING ST
Mailing Address - Street 2:SUITE 4R
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22302-1277
Mailing Address - Country:US
Mailing Address - Phone:703-845-0057
Mailing Address - Fax:
Practice Address - Street 1:4600 KING ST
Practice Address - Street 2:SUITE 4R
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22302-1277
Practice Address - Country:US
Practice Address - Phone:703-845-0057
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101058267207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD518598OtherNCPPO
DCK0520001OtherBC/BS DC
VA010096812Medicaid
VAP00220778OtherRRMC
VA010096812Medicaid
VAP00220778OtherRRMC