Provider Demographics
NPI:1780732941
Name:SELVAGE, CHRIS T (MD)
Entity type:Individual
Prefix:
First Name:CHRIS
Middle Name:T
Last Name:SELVAGE
Suffix:
Gender:M
Credentials:MD
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Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:16946 BURBANK BLVD
Mailing Address - Street 2:SUITE 106
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91316-1869
Mailing Address - Country:US
Mailing Address - Phone:818-990-0179
Mailing Address - Fax:818-990-0814
Practice Address - Street 1:16946 BURBANK BLVD
Practice Address - Street 2:SUITE 106
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91316-1869
Practice Address - Country:US
Practice Address - Phone:818-990-0179
Practice Address - Fax:818-990-0814
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-06
Last Update Date:2008-07-31
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAA305872084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A305870Medicaid
CA00A305870Medicaid
CAWA30587AMedicare PIN