Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208000000X | Pediatrician | MD028373E | GA |
NPI | 1003854563 |
---|---|
Provider Name | Vijayalakshmi Selvaraj |
First Address | Renfrew, PA 16053-9207 |
Second Address | Renfrew, PA 16053-9207 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 04/06/2006 |
Last Update Date | 13/06/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0015452650004 | (05) | PA |
G31700 | (02) |