Healthcare Provider Details

I. General information

NPI: 1417039371
Provider Name (Legal Business Name): SUNIL PUSHPAKUMARA PERERA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: SUNIL P PERERA M.D.

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 07/09/2007
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 Code207KA0200X
TaxonomyAllergy Physician
License NumberA30538
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: