Provider Demographics
NPI:1255918124
Name:GENEMO, EDOM ENDALE (MD)
Entity type:Individual
Prefix:
First Name:EDOM
Middle Name:ENDALE
Last Name:GENEMO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8316 ARLINGTON BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-5216
Mailing Address - Country:US
Mailing Address - Phone:703-573-2432
Mailing Address - Fax:
Practice Address - Street 1:8316 ARLINGTON BLVD STE 300
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-5216
Practice Address - Country:US
Practice Address - Phone:703-468-4195
Practice Address - Fax:703-280-9350
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-26
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA0101283017208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program