1548493315 NPI number — JANESRI DE SILVA M.D. A PROF CORP

Table of content: (NPI 1548493315)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548493315 NPI number — JANESRI DE SILVA M.D. A PROF CORP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JANESRI DE SILVA M.D. A PROF CORP
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1548493315
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/27/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
18543 DEVONSHIRE ST STE 430
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORTHRIDGE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91324-1308
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
818-361-5437
Provider Business Mailing Address Fax Number:
818-361-5695

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10550 SEPULVEDA BLVD
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
MISSION HILLS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91345-1934
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-361-5437
Provider Business Practice Location Address Fax Number:
818-361-5695
Provider Enumeration Date:
08/27/2009

Additional Information

Authorized Official

Authorized Official Last Name:
DE SILVA
Authorized Official First Name:
JANESRI
Authorized Official Middle Name:
WIJAYANGANI
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
818-361-5437

Provider Taxonomy Codes

  • Taxonomy code: 2080A0000X , with the licence number:  A88991 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: A88991 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00A889910 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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