Provider Demographics
NPI:1326256728
Name:SHANI KUMARASENA MD PC
Entity Type:Organization
Organization Name:SHANI KUMARASENA MD PC
Other - Org Name:NEWTON WELLESLEY CHILDREN'S DOCTOR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PEDIATRICIAN
Authorized Official - Prefix:
Authorized Official - First Name:DARSHINI
Authorized Official - Middle Name:
Authorized Official - Last Name:KUMARASENA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-235-5437
Mailing Address - Street 1:332 WASHINGTON ST
Mailing Address - Street 2:SUITE 260
Mailing Address - City:WELLESLEY
Mailing Address - State:MA
Mailing Address - Zip Code:02481
Mailing Address - Country:US
Mailing Address - Phone:781-235-5437
Mailing Address - Fax:781-235-3945
Practice Address - Street 1:332 WASHINGTON ST
Practice Address - Street 2:SUITE 260
Practice Address - City:WELLESLEY
Practice Address - State:MA
Practice Address - Zip Code:02481-6219
Practice Address - Country:US
Practice Address - Phone:781-235-5437
Practice Address - Fax:781-235-3945
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-18
Last Update Date:2008-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA150094208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9703667Medicaid
MAA21773Medicare PIN
MA9703667Medicaid