Provider Demographics
NPI:1932737251
Name:SOVIRAVONG, SELENA VIMONLATH (MD)
Entity type:Individual
Prefix:
First Name:SELENA
Middle Name:VIMONLATH
Last Name:SOVIRAVONG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:720 BROOKER CREEK BLVD STE 215
Mailing Address - Street 2:
Mailing Address - City:OLDSMAR
Mailing Address - State:FL
Mailing Address - Zip Code:34677-2937
Mailing Address - Country:US
Mailing Address - Phone:813-854-2003
Mailing Address - Fax:813-436-5378
Practice Address - Street 1:1854 OAK GROVE BLVD
Practice Address - Street 2:
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33559-8605
Practice Address - Country:US
Practice Address - Phone:813-948-6133
Practice Address - Fax:813-948-3460
Is Sole Proprietor?:No
Enumeration Date:2020-03-31
Last Update Date:2023-06-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME162216208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics