Healthcare Provider Details

I. General information

NPI: 1265400329
Provider Name (Legal Business Name): TILAK C GOONERATNE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

345 N MAIN ST STE 248
WEST HARTFORD CT
06117
US

IV. Provider business mailing address

345 N MAIN ST STE 248
WEST HARTFORD CT
06117
US

V. Phone/Fax

Practice location:
  • Phone: 860-231-8453
  • Fax: 860-523-4061
Mailing address:
  • Phone: 860-231-8453
  • Fax: 860-523-4061

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number023723
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: