1134457161 NPI number — DR. TEWODROS ASSEFA KIDANE MD, MSC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134457161 NPI number — DR. TEWODROS ASSEFA KIDANE MD, MSC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KIDANE
Provider First Name:
TEWODROS
Provider Middle Name:
ASSEFA
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD, MSC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1134457161
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/15/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
155 N FRESNO ST
Provider Second Line Business Mailing Address:
FAMILY & COMMUNITY MEDICINE DEPARTMENT
Provider Business Mailing Address City Name:
FRESNO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93701-2302
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
559-499-6450
Provider Business Mailing Address Fax Number:
559-499-6451

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
155 N FRESNO ST
Provider Second Line Business Practice Location Address:
FAMILY & COMMUNITY MEDICINE DEPARTMENT
Provider Business Practice Location Address City Name:
FRESNO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93701-2302
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
559-499-6450
Provider Business Practice Location Address Fax Number:
559-499-6451
Provider Enumeration Date:
12/02/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  A110208 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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