Provider Demographics
NPI:1104935832
Name:SELVAM, AYYASAMY P (MD)
Entity type:Individual
Prefix:DR
First Name:AYYASAMY
Middle Name:P
Last Name:SELVAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:AYYASAMY
Other - Middle Name:
Other - Last Name:PANNEERSELVAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 9080
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86313-9080
Mailing Address - Country:US
Mailing Address - Phone:928-776-6009
Mailing Address - Fax:928-776-6098
Practice Address - Street 1:500 N US HIGHWAY 89
Practice Address - Street 2:VA MEDICAL CENTER
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86313-5001
Practice Address - Country:US
Practice Address - Phone:928-776-6009
Practice Address - Fax:928-776-6098
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO108004207R00000X
KS04-26825207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine