1871646927 NPI number — DR. FASIKA WELDEAREGAY MD

Table of content: DR. FASIKA WELDEAREGAY MD (NPI 1871646927)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871646927 NPI number — DR. FASIKA WELDEAREGAY MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WELDEAREGAY
Provider First Name:
FASIKA
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1871646927
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/23/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 37174
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BALTIMORE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21297-3174
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
571-423-5699
Provider Business Mailing Address Fax Number:
571-423-5698

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2501 PARKERS LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALEXANDRIA
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22306-3209
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-664-7000
Provider Business Practice Location Address Fax Number:
703-664-7666
Provider Enumeration Date:
01/20/2007

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: 207RC0200X , with the licence number:  O101243690 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RP1001X , with the licence number: O101243690 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RC0200X , with the licence number: 0101243690 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1871646927 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".