MEDICARE: KEERTHI R DE SILVA M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	A30035	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1457359291
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEERTHI R DE SILVA M.D.

Provider Business Mailing Address
First Line	:	1141 W REDONDO BEACH BLVD
Second Line	:	SUITE 107
City	:	GARDENA
State	:	CA
Zip	:	90247-3586
Country	:	US
Telephone Number	:	310-515-0677
Fax Number	:	310-515-5033

Provider Business Practice Location Address
First Line	:	1141 W REDONDO BEACH BLVD
Second Line	:	SUITE 107
City	:	GARDENA
State	:	CA
Zip	:	90247-3586
Country	:	US
Telephone Number	:	310-515-0677
Fax Number	:	310-515-5033

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/13/2005
Last Update Date	:	03/28/2008

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