Basic Information
| Provider Information | |||||||||
| NPI: | 1972598423 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SELVARAJ | ||||||||
| FirstName: | ANANDA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1790 PORPOISE ST | ||||||||
| Address2: | |||||||||
| City: | MERRITT ISLAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329525640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3214592594 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1281 S PATRICK DR | ||||||||
| Address2: | 45TH MEDICAL GROUP | ||||||||
| City: | PATRICK AFB | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329253604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3214946412 | ||||||||
| FaxNumber: | 3214941378 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085B0100X | ME0048301 | FL | Y | Allopathic & Osteopathic Physicians | Radiology | Body Imaging | 2085B0100X | A032311 | CA | N | Allopathic & Osteopathic Physicians | Radiology | Body Imaging | 2085B0100X | 4301035614 | MI | N | Allopathic & Osteopathic Physicians | Radiology | Body Imaging |
No ID Information.