Healthcare Provider Details

I. General information

NPI: 1720723687
Provider Name (Legal Business Name): BEYENE TEWELDE GEBRESELASSIE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2022
Last Update Date: 07/08/2025
Certification Date: 07/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3020 S UNION AVE
TACOMA WA
98409-3317
US

IV. Provider business mailing address

917 PACIFIC AVE STE 600
TACOMA WA
98402-4437
US

V. Phone/Fax

Practice location:
  • Phone: 253-844-4327
  • Fax: 888-871-0613
Mailing address:
  • Phone: 253-844-4327
  • Fax: 888-871-0613

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberML61612263
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: