Healthcare Provider Details

I. General information

NPI: 1588633952
Provider Name (Legal Business Name): RICHARD A SELO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2006
Last Update Date: 03/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1345 UNITY PL SUITE 110
LAFAYETTE IN
47905-5768
US

IV. Provider business mailing address

PO BOX 4699
LAFAYETTE IN
47903-4699
US

V. Phone/Fax

Practice location:
  • Phone: 765-447-9308
  • Fax: 765-447-2387
Mailing address:
  • Phone: 765-449-2732
  • Fax: 765-449-1196

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number01035858A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: