Provider Demographics
NPI:1609307909
Name:SELVANAAYAGAM, REKHA
Entity Type:Individual
Prefix:
First Name:REKHA
Middle Name:
Last Name:SELVANAAYAGAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1069 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:SAUGUS
Mailing Address - State:MA
Mailing Address - Zip Code:01906-3210
Mailing Address - Country:US
Mailing Address - Phone:781-233-1450
Mailing Address - Fax:
Practice Address - Street 1:1069 BROADWAY
Practice Address - Street 2:
Practice Address - City:SAUGUS
Practice Address - State:MA
Practice Address - Zip Code:01906-3210
Practice Address - Country:US
Practice Address - Phone:781-233-1450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-27
Last Update Date:2021-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN11019389A207Q00000X
390200000X
MA283151207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program