Provider Demographics
NPI:1346298759
Name:SELASSIE, PETER G (MD)
Entity Type:Individual
Prefix:
First Name:PETER
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 1:1061 MEDICAL CENTER DR
Mailing Address - Street 2:SUITE 110
Mailing Address - City:ORANGE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32763-8200
Mailing Address - Country:US
Mailing Address - Phone:386-774-1223
Mailing Address - Fax:386-774-4658
Practice Address - Street 1:1061 MEDICAL CENTER DR
Practice Address - Street 2:SUITE 110
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763-8200
Practice Address - Country:US
Practice Address - Phone:386-774-1223
Practice Address - Fax:386-774-4658
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2010-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME36870174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL069666800Medicaid
FL05419YMedicare PIN
FL069666800Medicaid