Provider Demographics
NPI:1164595450
Name:GEBRESELASSIE, MEAZA (MD)
Entity Type:Individual
Prefix:DR
First Name:MEAZA
Middle Name:
Last Name:GEBRESELASSIE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 EAST JEFFERSON STREET
Mailing Address - Street 2:KAISER PERMANENTE MID ATLANTIC PERMANENTE MEDICAL GROUP
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-4908
Mailing Address - Country:US
Mailing Address - Phone:301-816-6660
Mailing Address - Fax:301-816-6308
Practice Address - Street 1:501 NORTH FREDERICK AVENUE
Practice Address - Street 2:
Practice Address - City:GALTHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20877-2598
Practice Address - Country:US
Practice Address - Phone:301-258-7265
Practice Address - Fax:301-258-7294
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2022-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101231342207R00000X
MDD57688207R00000X
DCMD33514207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
013860K92Medicare ID - Type Unspecified
H50413Medicare UPIN