Provider Demographics
NPI:1114253671
Name:JANESRI DE SILVA, MD A PROF CORP
Entity Type:Organization
Organization Name:JANESRI DE SILVA, MD A PROF CORP
Other - Org Name:KIDS & TEENS MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JANESRI
Authorized Official - Middle Name:WIJAYANGANI
Authorized Official - Last Name:DE SILVA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-782-7600
Mailing Address - Street 1:18543 DEVONSHIRE ST
Mailing Address - Street 2:SUITE 430
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91324-1308
Mailing Address - Country:US
Mailing Address - Phone:818-782-7600
Mailing Address - Fax:818-782-9077
Practice Address - Street 1:15211 VANOWEN ST
Practice Address - Street 2:SUITE 102
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91405-3606
Practice Address - Country:US
Practice Address - Phone:818-782-7600
Practice Address - Fax:818-782-9077
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-19
Last Update Date:2009-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA88991208000000X, 2080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A889910Medicaid