Healthcare Provider Details

I. General information

NPI: 1629202627
Provider Name (Legal Business Name): PRIYAN PERERA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/06/2009
Last Update Date: 07/28/2020
Certification Date: 07/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

815 S VASSAULT ST
TACOMA WA
98465
US

IV. Provider business mailing address

PO BOX 66657
SEATTLE WA
98166-0657
US

V. Phone/Fax

Practice location:
  • Phone: 253-444-3427
  • Fax:
Mailing address:
  • Phone: 206-453-1818
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD60536623
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberMD60536623
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: