Healthcare Provider Details

I. General information

NPI: 1083612980
Provider Name (Legal Business Name): ALLERGY MEDICAL GROUP OF THE NORTH AREA INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2005
Last Update Date: 04/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

935 RESERVE DR
ROSEVILLE CA
95678-1340
US

IV. Provider business mailing address

935 RESERVE DR
ROSEVILLE CA
95678-1340
US

V. Phone/Fax

Practice location:
  • Phone: 916-782-7758
  • Fax: 916-782-7770
Mailing address:
  • Phone: 916-782-7758
  • Fax: 916-782-7770

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number
License Number StateCA

VIII. Authorized Official

Name: SUNIL PUSHPAKUMARA PERERA
Title or Position: CEO OWNER
Credential: MD
Phone: 916-782-7758