Provider Demographics
NPI:1053545913
Name:SELVARAJ, PRADEEP KUMAR (MD)
Entity type:Individual
Prefix:
First Name:PRADEEP
Middle Name:KUMAR
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 1:178 HIGHWAY 24 E
Mailing Address - Street 2:
Mailing Address - City:CENTREVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39631-4171
Mailing Address - Country:US
Mailing Address - Phone:601-890-0500
Mailing Address - Fax:
Practice Address - Street 1:451 BANK ST
Practice Address - Street 2:
Practice Address - City:WOODVILLE
Practice Address - State:MS
Practice Address - Zip Code:39669-6000
Practice Address - Country:US
Practice Address - Phone:601-888-3421
Practice Address - Fax:601-888-3685
Is Sole Proprietor?:No
Enumeration Date:2009-05-07
Last Update Date:2017-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS22109207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine