Provider Demographics
NPI:1164427183
Name:SELVARAJ, MYLAPPAN (MD)
Entity Type:Individual
Prefix:DR
First Name:MYLAPPAN
Middle Name:
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 1:109 WINTERWOOD DR
Mailing Address - Street 2:
Mailing Address - City:BUTLER
Mailing Address - State:PA
Mailing Address - Zip Code:16001-2833
Mailing Address - Country:US
Mailing Address - Phone:724-679-4192
Mailing Address - Fax:724-482-1162
Practice Address - Street 1:777 NORTH ST
Practice Address - Street 2:
Practice Address - City:PITTSFIELD
Practice Address - State:MA
Practice Address - Zip Code:01201-4147
Practice Address - Country:US
Practice Address - Phone:724-545-9774
Practice Address - Fax:724-543-2945
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-16
Last Update Date:2020-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD-028840-E207RC0000X
MA42361207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PASE127889OtherBG & BS
PA01 1091654Medicaid
PA01 1091654Medicaid