Provider Demographics
NPI:1609842640
Name:BAGE, SEYOUM DAFFO (MD)
Entity Type:Individual
Prefix:
First Name:SEYOUM
Middle Name:DAFFO
Last Name:BAGE
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 1:800 GRAND CENTRAL MALL STE 10
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:WV
Mailing Address - Zip Code:26105-4100
Mailing Address - Country:US
Mailing Address - Phone:304-916-1288
Mailing Address - Fax:304-916-1289
Practice Address - Street 1:800 GRAND CENTRAL MALL STE 10
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:WV
Practice Address - Zip Code:26105-4100
Practice Address - Country:US
Practice Address - Phone:304-916-1288
Practice Address - Fax:304-916-1289
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2013-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV21587207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2502232Medicaid
WV3810000748Medicaid
OH2502232Medicaid
WV4142391Medicare ID - Type Unspecified