Provider Demographics
NPI:1629158878
Name:SELSTED, MICHAEL ERIC (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ERIC
Last Name:SELSTED
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 1:2011 ZONAL AVE
Mailing Address - Street 2:HMR 204
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90089-0110
Mailing Address - Country:US
Mailing Address - Phone:323-442-2582
Mailing Address - Fax:
Practice Address - Street 1:2011 ZONAL AVE
Practice Address - Street 2:HMR 204
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90089-0110
Practice Address - Country:US
Practice Address - Phone:323-442-2582
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG61278207ZP0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG63226Medicare UPIN
CA00G612780Medicaid
CA00G612780OtherBLUE SHIELD
CAWG61278AOtherMEDICARE PTAN