Provider Demographics
NPI:1023166832
Name:KETSELA, GIZATCHEW (MD)
Entity type:Individual
Prefix:
First Name:GIZATCHEW
Middle Name:
Last Name:KETSELA
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 1:2910 KERRY FOREST PKWY # D4-369
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32309-6892
Mailing Address - Country:US
Mailing Address - Phone:850-329-2872
Mailing Address - Fax:850-329-2882
Practice Address - Street 1:2709 KILLARNEY WAY STE 2
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32309-6201
Practice Address - Country:US
Practice Address - Phone:850-329-2872
Practice Address - Fax:850-329-2882
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD445869207RI0200X
GA71980207RI0200X
NY230027207RI0200X
FLME99953207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A816110Medicaid
GA003148794AMedicaid
FL001919000Medicaid
I25621Medicare UPIN
GA003148794AMedicaid