Provider Demographics
NPI:1356304869
Name:DESILVA, SURESH JAYANTHA (MD)
Entity Type:Individual
Prefix:
First Name:SURESH
Middle Name:JAYANTHA
Last Name:DESILVA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JAY
Other - Middle Name:JAYANTHA
Other - Last Name:DESILVA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:21332 NAUTIQUE BLVD
Mailing Address - Street 2:APT # 204
Mailing Address - City:CORNELIUS
Mailing Address - State:NC
Mailing Address - Zip Code:28031-6410
Mailing Address - Country:US
Mailing Address - Phone:704-650-3789
Mailing Address - Fax:
Practice Address - Street 1:21332 NAUTIQUE BLVD
Practice Address - Street 2:APT # 204
Practice Address - City:CORNELIUS
Practice Address - State:NC
Practice Address - Zip Code:28031-6410
Practice Address - Country:US
Practice Address - Phone:704-650-3789
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-07
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC00971315207P00000X
NV13961207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89107OLMedicaid
NC2246349FOtherMEDICARE PART B PROVIDER #
NC2246349FOtherMEDICARE PART B PROVIDER #
NC2246349WMedicare PIN
NC2076333Medicare PIN
NC89107OLMedicaid
NC2246349PMedicare PIN
NC2246349VMedicare PIN
NC2246349UMedicare PIN
NCG59557Medicare UPIN
NC2246349RMedicare PIN
NC2246349YMedicare PIN
NC2246349ZMedicare PIN
NC2246349NMedicare PIN
NC2246349TMedicare PIN
NC2076333AMedicare PIN