Provider Demographics
NPI:1255523338
Name:TESFAYE, DEREJE (CNMT)
Entity type:Individual
Prefix:
First Name:DEREJE
Middle Name:
Last Name:TESFAYE
Suffix:
Gender:M
Credentials:CNMT
Other - Prefix:
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Mailing Address - Street 1:5715 CAMERFORD AVE APT 106
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90038-3944
Mailing Address - Country:US
Mailing Address - Phone:213-804-5904
Mailing Address - Fax:
Practice Address - Street 1:5715 CAMERFORD AVE APT 106
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90038-3944
Practice Address - Country:US
Practice Address - Phone:213-804-5904
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-13
Last Update Date:2007-08-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CARHN27192471N0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2471N0900XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistNuclear Medicine Technology