Provider Demographics
NPI:1225034135
Name:SELASSIE, MAHTEME (MD)
Entity type:Individual
Prefix:
First Name:MAHTEME
Middle Name:
Last Name:SELASSIE
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 1:7910 WOODMONT AVE
Mailing Address - Street 2:STE 460
Mailing Address - City:BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20814-3066
Mailing Address - Country:US
Mailing Address - Phone:301-934-8811
Mailing Address - Fax:301-934-9321
Practice Address - Street 1:7910 WOODMONT AVE
Practice Address - Street 2:STE 460
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20814-3066
Practice Address - Country:US
Practice Address - Phone:301-934-8811
Practice Address - Fax:301-934-9321
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-24
Last Update Date:2007-07-08
Deactivation Date:2006-03-16
Deactivation Code:
Reactivation Date:2006-03-21
Provider Licenses
StateLicense IDTaxonomies
MD049442084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD567898OtherNCPPO
MD141971OtherVALUE OPTIONS
DCM5790001OtherBLUE CROSS
MD2129679OtherMAMSI/ALLIANCE
MD583BMAOtherBLUE CROSS
DCG01892Medicare ID - Type UnspecifiedTRAILBLAZER
MD141971OtherVALUE OPTIONS