Provider Demographics
NPI:1295001790
Name:KARIYAWASAM, CHARMY (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARMY
Middle Name:
Last Name:KARIYAWASAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:813 ORLEANS DR
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-1318
Mailing Address - Country:US
Mailing Address - Phone:203-417-6768
Mailing Address - Fax:
Practice Address - Street 1:1300 W TERRELL AVE STE K230
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2820
Practice Address - Country:US
Practice Address - Phone:817-250-4906
Practice Address - Fax:817-250-4815
Is Sole Proprietor?:No
Enumeration Date:2012-03-28
Last Update Date:2022-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT53838207R00000X
TXQ4438207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX520025YKPWMedicare PIN