Provider Demographics
NPI:1750137170
Name:TESFAYE, EMANUEL A
Entity type:Individual
Prefix:
First Name:EMANUEL
Middle Name:A
Last Name:TESFAYE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:879 E HERITAGE DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43213-3180
Mailing Address - Country:US
Mailing Address - Phone:502-888-3666
Mailing Address - Fax:
Practice Address - Street 1:879 E HERITAGE DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43213-3180
Practice Address - Country:US
Practice Address - Phone:502-888-3666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-26
Last Update Date:2024-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHVT262619172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172A00000XOther Service ProvidersDriverGroup - Single Specialty