Basic Information
| Provider Information | |||||||||
| NPI: | 1164595450 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GEBRESELASSIE | ||||||||
| FirstName: | MEAZA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2101 EAST JEFFERSON STREET | ||||||||
| Address2: | KAISER PERMANENTE MID ATLANTIC PERMANENTE MEDICAL GROUP | ||||||||
| City: | ROCKVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208524908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3018166660 | ||||||||
| FaxNumber: | 3018166308 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 NORTH FREDERICK AVENUE | ||||||||
| Address2: | |||||||||
| City: | GALTHERSBURG | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208772598 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3012587265 | ||||||||
| FaxNumber: | 3012587294 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2006 | ||||||||
| LastUpdateDate: | 01/20/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 0101231342 | VA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | D57688 | MD | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | MD33514 | DC | N | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.