Provider Demographics
NPI:1801884408
Name:TEFFERA, FASSIL (MD)
Entity type:Individual
Prefix:MR
First Name:FASSIL
Middle Name:
Last Name:TEFFERA
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 1:2426 EASTCHESTER RD
Mailing Address - Street 2:#101
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10469-5947
Mailing Address - Country:US
Mailing Address - Phone:718-708-4726
Mailing Address - Fax:718-708-7599
Practice Address - Street 1:2426 EASTCHESTER RD
Practice Address - Street 2:#101
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10469
Practice Address - Country:US
Practice Address - Phone:718-708-4726
Practice Address - Fax:718-708-7599
Is Sole Proprietor?:No
Enumeration Date:2005-10-09
Last Update Date:2011-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY196877207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01527384Medicaid
NY22K59Medicare ID - Type Unspecified
NY01527384Medicaid