Provider Demographics
NPI:1023080181
Name:SELVARAJ, KAVITHA (MD)
Entity type:Individual
Prefix:
First Name:KAVITHA
Middle Name:
Last Name:SELVARAJ
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 1:350 SPARTA AVE
Mailing Address - Street 2:B6B
Mailing Address - City:SPARTA
Mailing Address - State:NJ
Mailing Address - Zip Code:07871-1150
Mailing Address - Country:US
Mailing Address - Phone:973-729-9122
Mailing Address - Fax:973-729-3358
Practice Address - Street 1:350 SPARTA AVE
Practice Address - Street 2:B6B
Practice Address - City:SPARTA
Practice Address - State:NJ
Practice Address - Zip Code:07871-1150
Practice Address - Country:US
Practice Address - Phone:973-729-9122
Practice Address - Fax:973-729-3358
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-03
Last Update Date:2009-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07568800207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0023833Medicaid
NJI03785Medicare UPIN
NJ077795Medicare ID - Type Unspecified