Healthcare Provider Details

I. General information

NPI: 1346222536
Provider Name (Legal Business Name): LULSEGED G SELASSIE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2005
Last Update Date: 11/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1150 VARNUM ST NE PATHOLOGY DEPARTMENT
WASHINGTON DC
20017-2180
US

IV. Provider business mailing address

PO BOX 70688
WASHINGTON DC
20024-0688
US

V. Phone/Fax

Practice location:
  • Phone: 202-269-7242
  • Fax:
Mailing address:
  • Phone: 410-872-9188
  • Fax: 410-872-9169

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberMD206468
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberD0045364
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number0101054299
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: