Provider Demographics
NPI:1396826012
Name:PEREIRA, SELWYN JACK (MD)
Entity Type:Individual
Prefix:
First Name:SELWYN
Middle Name:JACK
Last Name:PEREIRA
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 1:500 EAST 77TH ST
Mailing Address - Street 2:APT 1815
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10162
Mailing Address - Country:US
Mailing Address - Phone:212-879-6207
Mailing Address - Fax:
Practice Address - Street 1:775 PARK AVE
Practice Address - Street 2:STE 1105
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743
Practice Address - Country:US
Practice Address - Phone:631-784-7704
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0797742084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
038092OtherVALUE OPTIONS
NY0036914OtherGHI
038092OtherVALUE OPTIONS
NY0036914OtherGHI