Healthcare Provider Details

I. General information

NPI: 1053303958
Provider Name (Legal Business Name): POLLACHI P SELVAKUMARRAJ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2005
Last Update Date: 10/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 E WASHINGTON AVE
NAVASOTA TX
77868-3001
US

IV. Provider business mailing address

2800 S TEXAS AVE STE 202
BRYAN TX
77802-5361
US

V. Phone/Fax

Practice location:
  • Phone: 936-825-6444
  • Fax:
Mailing address:
  • Phone: 979-774-2053
  • Fax: 979-776-5914

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberL1195
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: