Provider Demographics
NPI:1891445169
Name:PANNEER SELVAM, PAVALAN (MBBS)
Entity Type:Individual
Prefix:DR
First Name:PAVALAN
Middle Name:
Last Name:PANNEER SELVAM
Suffix:
Gender:M
Credentials:MBBS
Other - Prefix:DR
Other - First Name:PAVALAN
Other - Middle Name:
Other - Last Name:PANNEER SELVAM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MBBS
Mailing Address - Street 1:295 S CHIPETA WAY RM 2W245
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84108-1287
Mailing Address - Country:US
Mailing Address - Phone:801-581-2121
Mailing Address - Fax:
Practice Address - Street 1:295 S CHIPETA WAY RM 2W245
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84108-1287
Practice Address - Country:US
Practice Address - Phone:801-581-2121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-28
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13521401-1205208000000X, 207SG0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207SG0201XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Genetics (M.D.)
No208000000XAllopathic & Osteopathic PhysiciansPediatrics