Provider Demographics
NPI:1780769083
Name:BELAY, ANTENEH M (MD)
Entity type:Individual
Prefix:
First Name:ANTENEH
Middle Name:M
Last Name:BELAY
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 1:1820 SOUTHMORE BLVD
Mailing Address - Street 2:UNIT D.
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77004-5947
Mailing Address - Country:US
Mailing Address - Phone:703-888-8259
Mailing Address - Fax:
Practice Address - Street 1:2300 OPITZ BLVD
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22191-3311
Practice Address - Country:US
Practice Address - Phone:703-670-1313
Practice Address - Fax:904-346-0113
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2008-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101240085207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAP00370390OtherRAILROAD MEDICARE
VA010345197Medicaid
VA012145B76Medicare PIN
VA010345197Medicaid