Provider Demographics
NPI:1811941941
Name:TAFARI, GASHAW TEDLA (MD)
Entity type:Individual
Prefix:
First Name:GASHAW
Middle Name:TEDLA
Last Name:TAFARI
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 1:6720 JOLIETTE LN
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28277
Mailing Address - Country:US
Mailing Address - Phone:704-543-1388
Mailing Address - Fax:
Practice Address - Street 1:225 S HERLONG AVE STE 250
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-2147
Practice Address - Country:US
Practice Address - Phone:803-325-8742
Practice Address - Fax:803-325-2369
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2011-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2019226208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC19226Medicare UPIN