Provider Demographics
NPI:1972598423
Name:SELVARAJ, ANANDA (MD)
Entity type:Individual
Prefix:
First Name:ANANDA
Middle Name:
Last Name:SELVARAJ
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 1:1790 PORPOISE ST
Mailing Address - Street 2:
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32952-5640
Mailing Address - Country:US
Mailing Address - Phone:321-459-2594
Mailing Address - Fax:
Practice Address - Street 1:1281 S PATRICK DR
Practice Address - Street 2:45TH MEDICAL GROUP
Practice Address - City:PATRICK AFB
Practice Address - State:FL
Practice Address - Zip Code:32925-3604
Practice Address - Country:US
Practice Address - Phone:321-494-6412
Practice Address - Fax:321-494-1378
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME00483012085B0100X
CAA0323112085B0100X
MI43010356142085B0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
Provider Identifiers
StateIdentifier IDID TypeIssuer
UAD000Medicare UPIN