Healthcare Provider Details

I. General information

NPI: 1336792662
Provider Name (Legal Business Name): PREETHI CONJEEVARAM SELVAKUMAR MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: PREETHI C S MD

II. Dates (important events)

Enumeration Date: 07/16/2019
Last Update Date: 11/07/2024
Certification Date: 11/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 DELBON AVE
TURLOCK CA
95382-2021
US

IV. Provider business mailing address

1910 CUSTOMER CARE WAY
ATWATER CA
95301-5167
US

V. Phone/Fax

Practice location:
  • Phone: 209-722-4842
  • Fax:
Mailing address:
  • Phone: 209-722-4842
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA190095
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: