Healthcare Provider Details

I. General information

NPI: 1326278490
Provider Name (Legal Business Name): JANESRI DE SILVA M.D. A PROF CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2009
Last Update Date: 06/15/2020
Certification Date: 06/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

504 S SIERRA MADRE BLVD
PASADENA CA
91107-5240
US

IV. Provider business mailing address

504 S SIERRA MADRE BLVD
PASADENA CA
91107-5240
US

V. Phone/Fax

Practice location:
  • Phone: 818-361-5437
  • Fax: 626-406-1800
Mailing address:
  • Phone: 818-361-5437
  • Fax: 626-406-1800

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License NumberA88991
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA88991
License Number StateCA

VIII. Authorized Official

Name: DR. JANESRI WIJAYANGANI DE SILVA
Title or Position: PRESIDENT
Credential: M.D
Phone: 818-361-5437