Provider Demographics
NPI:1184779415
Name:FEYSSA, EYOB L (MD, MPH, FACP)
Entity type:Individual
Prefix:DR
First Name:EYOB
Middle Name:L
Last Name:FEYSSA
Suffix:
Gender:M
Credentials:MD, MPH, FACP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5401 OLD YORK RD
Mailing Address - Street 2:KLEIN SUITE 505
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19141-3030
Mailing Address - Country:US
Mailing Address - Phone:215-456-8242
Mailing Address - Fax:215-456-8058
Practice Address - Street 1:5401 OLD YORK RD
Practice Address - Street 2:KLEIN SUITE 505
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19141-3030
Practice Address - Country:US
Practice Address - Phone:215-456-8242
Practice Address - Fax:215-456-8058
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM5704207RI0008X
NJ25MA08117400207RI0008X
PAMD430800207R00000X, 207RG0100X, 207RI0008X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RI0008XAllopathic & Osteopathic PhysiciansInternal MedicineHepatology
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101978752Medicaid
PA114416Medicare PIN