1497836100 NPI number — DR. SEFANIT FASSIL M.D.

Table of content: DR. SEFANIT FASSIL M.D. (NPI 1497836100)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497836100 NPI number — DR. SEFANIT FASSIL M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FASSIL
Provider First Name:
SEFANIT
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

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:
1497836100
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3645 ELDER OAKS BLVD
Provider Second Line Business Mailing Address:
#7108
Provider Business Mailing Address City Name:
BOWIE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20716-3381
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-464-2156
Provider Business Mailing Address Fax Number:
410-263-4086

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 FORBES ST
Provider Second Line Business Practice Location Address:
STE 200
Provider Business Practice Location Address City Name:
ANNAPOLIS
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21401-1538
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-263-6363
Provider Business Practice Location Address Fax Number:
410-263-4086
Provider Enumeration Date:
10/18/2006

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: 208000000X , with the licence number:  D0043194 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: M34850 . This is a "CONTROLLED SUBSTANCE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: D0043194 . This is a "MEDICAL LICENSE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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