Healthcare Provider Details

I. General information

NPI: 1295079630
Provider Name (Legal Business Name): SELVON NANAN M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/26/2012
Last Update Date: 11/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 NW 70TH AVE 206
PLANTATION FL
33317-2385
US

IV. Provider business mailing address

333 NW 70TH AVE 206
PLANTATION FL
33317-2385
US

V. Phone/Fax

Practice location:
  • Phone: 954-557-5703
  • Fax:
Mailing address:
  • Phone: 954-557-5703
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberME45555
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: