1538797774 NPI number — DR. WONDWOSEN DEMISSIE TADESSE MD

Table of content: DR. WONDWOSEN DEMISSIE TADESSE MD (NPI 1538797774)

General
Organization/Personal Information
Provider's Other Name Information
NPI Number Information
Provider's Business Mailing Address
Provider's Practice Location Mailing Address
Additional Information
Authorized Official
Provider Taxonomy Codes
Other Provider's Identifiers (legacy, non-NPI)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538797774 NPI number — DR. WONDWOSEN DEMISSIE TADESSE MD

Organization/Personal Information

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:
TADESSE

Provider First Name:
WONDWOSEN

Provider Middle Name:
DEMISSIE

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:
1538797774

Entity Type Code:
Individual

Replacement NPI:

Last Update Date:
08/02/2021

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
WVU NEUROLOGY

Provider Second Line Business Mailing Address:
5TH FLOOR POC PO BOX 0782

Provider Business Mailing Address City Name:
MORGANTOWN

Provider Business Mailing Address State Name:
WV

Provider Business Mailing Address Postal Code:
26507

Provider Business Mailing Address Country Code:
US

Provider Business Mailing Address Telephone Number:

Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
UNIVERSITY OF MARYLAND PRINCE GEORGE'S HOSPITAL CENTER

Provider Second Line Business Practice Location Address:
DEPARTMENT OF MEDICINE 3001 HOSPITAL DRIVE 5TH FLOOR

Provider Business Practice Location Address City Name:
CHEVERLY

Provider Business Practice Location Address State Name:
MD

Provider Business Practice Location Address Postal Code:
20785

Provider Business Practice Location Address Country Code:
US

Provider Business Practice Location Address Telephone Number:
301-618-2273

Provider Business Practice Location Address Fax Number:
301-429-1949

Provider Enumeration Date:
04/01/2020

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: 390200000X , with the licence number: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .