Provider Demographics
NPI:1720723687
Name:GEBRESELASSIE, BEYENE TEWELDE (MD)
Entity type:Individual
Prefix:
First Name:BEYENE
Middle Name:TEWELDE
Last Name:GEBRESELASSIE
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 1:917 PACIFIC AVE STE 600
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98402-4437
Mailing Address - Country:US
Mailing Address - Phone:253-844-4327
Mailing Address - Fax:888-871-0613
Practice Address - Street 1:3020 S UNION AVE
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98409-3317
Practice Address - Country:US
Practice Address - Phone:253-844-4327
Practice Address - Fax:888-871-0613
Is Sole Proprietor?:No
Enumeration Date:2022-05-04
Last Update Date:2025-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WAML61612263207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program