Provider Demographics
NPI:1134788532
Name:AJEBO, ETSUBDENK MEZEMIR (MD)
Entity type:Individual
Prefix:
First Name:ETSUBDENK
Middle Name:MEZEMIR
Last Name:AJEBO
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4211 FAIRFAX CORNER AVE E STE 225
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-8623
Mailing Address - Country:US
Mailing Address - Phone:703-280-1372
Mailing Address - Fax:
Practice Address - Street 1:4211 FAIRFAX CORNER AVE E STE 225
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-8623
Practice Address - Country:US
Practice Address - Phone:703-278-2473
Practice Address - Fax:703-239-4857
Is Sole Proprietor?:No
Enumeration Date:2019-06-10
Last Update Date:2025-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD7730D97154207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology