# TESFAYE D FANTA MD PLLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1033489216
- **Authorized official:** DR. TESFAYE DEMISSIE FANTA MD (OWNER)
- **Authorized official phone:** (336) 342-9564

## Contact information

- **Practice address:** 910 W HARRISON ST, REIDSVILLE, NC 27320-3324
- **Practice address phone:** (336) 342-9564
- **Practice address fax:** (336) 349-9723
- **Mailing address:** 910 W HARRISON ST, REIDSVILLE, NC 27320-3324
- **Mailing address phone:** (336) 342-9564
- **Mailing address fax:** (336) 349-9723

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207RE0101X | Endocrinology, Diabetes & Metabolism Physician | 200900231 | NC | Yes |

## Other

- **Enumeration date:** 01/05/2012
- **Last updated:** 01/05/2012

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 1066A | BCBS | NC |
| 01 | — | 1522X | BCBS | NC |
| 05 | — | 5911977 | — | NC |
| 05 | — | 891066A | — | NC |