Provider Demographics
NPI:1295705325
Name:AYO, DEREJE (MD)
Entity type:Individual
Prefix:
First Name:DEREJE
Middle Name:
Last Name:AYO
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:PO BOX 16284
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76162-0284
Mailing Address - Country:US
Mailing Address - Phone:817-568-8411
Mailing Address - Fax:817-568-8414
Practice Address - Street 1:11803 SOUTH FWY STE 311
Practice Address - Street 2:
Practice Address - City:BURLESON
Practice Address - State:TX
Practice Address - Zip Code:76028-7036
Practice Address - Country:US
Practice Address - Phone:817-568-8411
Practice Address - Fax:817-568-8414
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2021-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN0617207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXN0617OtherTEXAS LICENSE
TX8L5062Medicare PIN