Provider Demographics
NPI:1568880102
Name:SELVADURAY, PRAVEENA (MD, PHD)
Entity Type:Individual
Prefix:
First Name:PRAVEENA
Middle Name:
Last Name:SELVADURAY
Suffix:
Gender:F
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 SUTTER ST FL 2
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94104-4009
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:595 CASTRO ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94114
Practice Address - Country:US
Practice Address - Phone:415-529-4099
Practice Address - Fax:415-291-0489
Is Sole Proprietor?:No
Enumeration Date:2014-04-01
Last Update Date:2019-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA139421207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine