Basic Information
| Provider Information | |||||||||
| NPI: | 1720154545 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KASSAYE | ||||||||
| FirstName: | SEBLE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1220 12TH ST SE | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 200033722 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2027157900 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1220 12TH ST SE | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 200033722 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2027157900 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/24/2006 | ||||||||
| LastUpdateDate: | 10/21/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0200X | A778880 | CA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease | 207RI0200X | MD038263 | DC | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease | 207RI0200X | 0101250530 | VA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
ID Information
| ID | Type | State | Issuer | Description | 00A778880 | 05 | CA | MEDICAID |