Healthcare Provider Details

I. General information

NPI: 1629253364
Provider Name (Legal Business Name): JASON BUDDIKA SAMARASENA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/31/2007
Last Update Date: 01/24/2025
Certification Date: 01/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 THE CITY DR S BUILDING 200, SUITE 720
ORANGE CA
92868-3201
US

IV. Provider business mailing address

363 NEWPORT AVE UNIT 317
LONG BEACH CA
90814-2661
US

V. Phone/Fax

Practice location:
  • Phone: 714-456-6693
  • Fax: 714-456-8874
Mailing address:
  • Phone: 562-438-2330
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA100124
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberA100124
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: