Basic Information
| Provider Information | |||||||||
| NPI: | 1396910501 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TEKLE | ||||||||
| FirstName: | TESFAI | ||||||||
| MiddleName: | JULIEN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | TEKLE | ||||||||
| OtherFirstName: | TESFAY | ||||||||
| OtherMiddleName: | JULIEN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 909 FROSTWOOD DR STE 1.100 | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770242301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7133386353 | ||||||||
| FaxNumber: | 7137043086 | ||||||||
| Practice Location | |||||||||
| Address1: | 17500 W GRAND PKWY S | ||||||||
| Address2: | |||||||||
| City: | SUGAR LAND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 774792562 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2817255026 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/29/2008 | ||||||||
| LastUpdateDate: | 06/12/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD.203526 | LA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | S0578 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 01069964A | IN | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | S0578 | TX | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 201045260 | 05 | IN | MEDICAID |