Provider Demographics
NPI:1245852284
Name:LEGESSE, DEREJE SEYOUM (MD)
Entity type:Individual
Prefix:
First Name:DEREJE
Middle Name:SEYOUM
Last Name:LEGESSE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3041 CEDAR CREEK PKWY
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-4415
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:745 POPLAR RD
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-1618
Practice Address - Country:US
Practice Address - Phone:770-400-2353
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-13
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA99350208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist