Provider Demographics
NPI:1245490382
Name:HAILU, TESFU (MD)
Entity type:Individual
Prefix:DR
First Name:TESFU
Middle Name:
Last Name:HAILU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4909 N GLEN PARK PLACE RD
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-4689
Mailing Address - Country:US
Mailing Address - Phone:309-674-7546
Mailing Address - Fax:309-282-2075
Practice Address - Street 1:4909 N GLEN PARK PLACE RD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-4676
Practice Address - Country:US
Practice Address - Phone:309-674-7546
Practice Address - Fax:309-691-9286
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-12
Last Update Date:2020-05-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036151973207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology