Provider Demographics
NPI:1548256399
Name:SELVARAJAH, NIRANJAN M (MD)
Entity type:Individual
Prefix:
First Name:NIRANJAN
Middle Name:M
Last Name:SELVARAJAH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1729 BURRSTONE ROAD
Mailing Address - Street 2:SLOCUM DICKSON MEDICAL GROUP
Mailing Address - City:NEW HARTFORD
Mailing Address - State:NY
Mailing Address - Zip Code:13413-6680
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1729 BURRSTONE ROAD
Practice Address - Street 2:SLOCUM DICKSON MEDICAL GROUP
Practice Address - City:NEW HARTFORD
Practice Address - State:NY
Practice Address - Zip Code:13413-6680
Practice Address - Country:US
Practice Address - Phone:315-798-1700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-26
Last Update Date:2011-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY238340207Q00000X, 207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02936689Medicaid
NY02936689Medicaid