Provider Demographics
NPI:1184229981
Name:TESFAYE, DAWIT
Entity type:Individual
Prefix:
First Name:DAWIT
Middle Name:
Last Name:TESFAYE
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 1:150 E ILLINOIS AVE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75216-2204
Mailing Address - Country:US
Mailing Address - Phone:214-944-5857
Mailing Address - Fax:214-919-4578
Practice Address - Street 1:150 E ILLINOIS AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75216-2204
Practice Address - Country:US
Practice Address - Phone:214-944-5857
Practice Address - Fax:214-919-4578
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-01
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX63495183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty