1376653089 NPI number — KUMUDINIE C FONSEKA MD

Table of content: KUMUDINIE C FONSEKA MD (NPI 1376653089)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376653089 NPI number — KUMUDINIE C FONSEKA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FONSEKA
Provider First Name:
KUMUDINIE
Provider Middle Name:
C
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1376653089
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/22/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
21327 HARPER AVENUE
Provider Second Line Business Mailing Address:
SUITE D
Provider Business Mailing Address City Name:
ST CLAIR SHORES
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48080
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
586-772-2300
Provider Business Mailing Address Fax Number:
586-772-7111

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
21327 HARPER AVENUE
Provider Second Line Business Practice Location Address:
SUITE D
Provider Business Practice Location Address City Name:
ST CLAIR SHORES
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48080
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
586-772-2300
Provider Business Practice Location Address Fax Number:
586-772-7111
Provider Enumeration Date:
08/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  4301049484 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1943271 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com