Organization
TESFAYE D FANTA MD PLLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. TESFAYE DEMISSIE FANTA MD (OWNER)
(336) 342-9564
Entity
Organization
Contact information
Practice address
910 W HARRISON ST, REIDSVILLE, NC 27320-3324
(336) 342-9564
(336) 349-9723
Mailing address
910 W HARRISON ST, REIDSVILLE, NC 27320-3324
(336) 342-9564
(336) 349-9723
Taxonomy
Speciality
Code
Description
License number
State
207RE0101X
Endocrinology, Diabetes & Metabolism Physician
Primary
200900231
NC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1066A
BCBS
NC
01
—
1522X
BCBS
NC
05
—
5911977
—
NC
05
—
891066A
—
NC
Enumeration date
01/05/2012
Last updated
01/05/2012
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