Provider Demographics
NPI:1205601150
Name:WELDETSADIK, MERON
Entity type:Individual
Prefix:
First Name:MERON
Middle Name:
Last Name:WELDETSADIK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8861 BRANCH AVE # 1285
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MD
Mailing Address - Zip Code:20735-2632
Mailing Address - Country:US
Mailing Address - Phone:571-250-9629
Mailing Address - Fax:
Practice Address - Street 1:6412 HORSESHOE RD
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MD
Practice Address - Zip Code:20735-2533
Practice Address - Country:US
Practice Address - Phone:571-250-9629
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-21
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172A00000X
MD9EE0802172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver