Provider Demographics
NPI:1992764625
Name:SELVARAJ, RAJAKUMARI PRAKASH (MD)
Entity type:Individual
Prefix:
First Name:RAJAKUMARI
Middle Name:PRAKASH
Last Name:SELVARAJ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:363 REMINGTON BLVD.
Mailing Address - Street 2:SUITE 340
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-3442
Mailing Address - Country:US
Mailing Address - Phone:630-759-9800
Mailing Address - Fax:630-759-9858
Practice Address - Street 1:393 REMINGTON BLVD.
Practice Address - Street 2:SUITE 340
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60440-3442
Practice Address - Country:US
Practice Address - Phone:630-759-9800
Practice Address - Fax:630-759-9858
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2008-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-105260207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILH52573Medicare UPIN