Provider Demographics
NPI:1255326393
Name:SELVAGGI, THOMAS C (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:C
Last Name:SELVAGGI
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 1:1705 LIVE OAK ST
Mailing Address - Street 2:
Mailing Address - City:COMMERCE
Mailing Address - State:TX
Mailing Address - Zip Code:75428-2551
Mailing Address - Country:US
Mailing Address - Phone:903-886-8818
Mailing Address - Fax:903-886-8765
Practice Address - Street 1:1705 LIVE OAK ST
Practice Address - Street 2:
Practice Address - City:COMMERCE
Practice Address - State:TX
Practice Address - Zip Code:75428-2551
Practice Address - Country:US
Practice Address - Phone:903-886-8818
Practice Address - Fax:903-886-8765
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-14
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH0803207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX13808104Medicaid
TX111557802Medicaid
TX111557801Medicaid
TX111557801Medicaid
TX13808104Medicaid