Healthcare Provider Details

I. General information

NPI: 1104881523
Provider Name (Legal Business Name): MOHAN PRIYAKANTHA KUMARATNE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

Provider Other Name: MOHAN PRIYAKANTHA KUMARARATNE M.D.

II. Dates (important events)

Enumeration Date: 04/19/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17692 BEACH BLVD STE. 200
HUNTINGTON BEACH CA
92647-6837
US

IV. Provider business mailing address

17692 BEACH BLVD STE. 200
HUNTINGTON BEACH CA
92647-6837
US

V. Phone/Fax

Practice location:
  • Phone: 714-847-6975
  • Fax: 714-847-9727
Mailing address:
  • Phone: 714-847-6975
  • Fax: 714-847-9727

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License NumberA35327
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: