Healthcare Provider Details

I. General information

NPI: 1194901025
Provider Name (Legal Business Name): YASANGI MARINA JAYASINHA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2008
Last Update Date: 01/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 HIGHWAY K SUITE 4
O FALLON MO
63366-8423
US

IV. Provider business mailing address

1001 HIGHWAY K SUITE 4
O FALLON MO
63366-8423
US

V. Phone/Fax

Practice location:
  • Phone: 636-240-9896
  • Fax:
Mailing address:
  • Phone: 636-240-9896
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2007002167
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: