Provider Demographics
NPI:1053303958
Name:SELVAKUMARRAJ, POLLACHI P (MD)
Entity Type:Individual
Prefix:
First Name:POLLACHI
Middle Name:P
Last Name:SELVAKUMARRAJ
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 1:2800 S TEXAS AVE
Mailing Address - Street 2:STE 202
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77802-5361
Mailing Address - Country:US
Mailing Address - Phone:979-774-2053
Mailing Address - Fax:979-776-5914
Practice Address - Street 1:501 E WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:NAVASOTA
Practice Address - State:TX
Practice Address - Zip Code:77868-3001
Practice Address - Country:US
Practice Address - Phone:936-825-6444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-17
Last Update Date:2017-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL1195207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXL1195OtherPHYSICIAN PERMIT
TX029966101Medicaid
G53822Medicare UPIN
TX029966101Medicaid