Provider Demographics
NPI:1801855697
Name:MAHTEME SELASSIE, MDPA
Entity Type:Organization
Organization Name:MAHTEME SELASSIE, MDPA
Other - Org Name:MAHTEME SELASSIE, MDPA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MAHTEME
Authorized Official - Middle Name:
Authorized Official - Last Name:SELASSIE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-656-9520
Mailing Address - Street 1:7910 WOODMONT AVE
Mailing Address - Street 2:SUITE 460
Mailing Address - City:BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20814-3002
Mailing Address - Country:US
Mailing Address - Phone:301-656-9520
Mailing Address - Fax:301-718-3633
Practice Address - Street 1:7910 WOODMONT AVE
Practice Address - Street 2:SUITE 460
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20814-3002
Practice Address - Country:US
Practice Address - Phone:301-656-9520
Practice Address - Fax:301-718-3633
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-21
Last Update Date:2007-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD00526862084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDM44625OtherCDS
MDD0052686OtherSTATE LICENSE
MDG01892Medicare PIN
MDM44625OtherCDS