Provider Demographics
NPI:1891115903
Name:SELVAM, PRABU (MD)
Entity Type:Individual
Prefix:DR
First Name:PRABU
Middle Name:
Last Name:SELVAM
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 1:856 J CLYDE MORRIS BLVD
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23601-1318
Mailing Address - Country:US
Mailing Address - Phone:757-316-5800
Mailing Address - Fax:757-534-5190
Practice Address - Street 1:20480 MARKET ST
Practice Address - Street 2:
Practice Address - City:ONANCOCK
Practice Address - State:VA
Practice Address - Zip Code:23417-4309
Practice Address - Country:US
Practice Address - Phone:757-302-2350
Practice Address - Fax:757-789-0615
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-16
Last Update Date:2021-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA0101259565207P00000X
MDD90789207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program