Provider Demographics
NPI:1528597002
Name:JUAREZ, SELINA (MD)
Entity Type:Individual
Prefix:
First Name:SELINA
Middle Name:
Last Name:JUAREZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 GROVE RD FL 3
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29605-4210
Mailing Address - Country:US
Mailing Address - Phone:864-455-1435
Mailing Address - Fax:
Practice Address - Street 1:701 GROVE ROAD
Practice Address - Street 2:3RD FLOOR SUPPORT TOWER
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605
Practice Address - Country:US
Practice Address - Phone:864-455-1435
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC41135208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty