Provider Demographics
NPI:1346222536
Name:SELASSIE, LULSEGED G (MD)
Entity Type:Individual
Prefix:DR
First Name:LULSEGED
Middle Name:G
Last Name:SELASSIE
Suffix:
Gender:M
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:PO BOX 70688
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20024-0688
Mailing Address - Country:US
Mailing Address - Phone:410-872-9188
Mailing Address - Fax:410-872-9169
Practice Address - Street 1:1150 VARNUM ST NE
Practice Address - Street 2:PATHOLOGY DEPARTMENT
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20017-2180
Practice Address - Country:US
Practice Address - Phone:202-269-7242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-15
Last Update Date:2011-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD206468207ZP0102X
MDD0045364207ZP0102X
VA0101054299207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCF72683Medicare UPIN
DC517533M89Medicare ID - Type UnspecifiedMEDICARE INDIVIDUAL #