Provider Demographics
NPI:1417039371
Name:PERERA, SUNIL PUSHPAKUMARA (MD)
Entity Type:Individual
Prefix:
First Name:SUNIL
Middle Name:PUSHPAKUMARA
Last Name:PERERA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:SUNIL
Other - Middle Name:P
Other - Last Name:PERERA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:935 RESERVE DR
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95678-1340
Mailing Address - Country:US
Mailing Address - Phone:916-782-7758
Mailing Address - Fax:916-782-7770
Practice Address - Street 1:935 RESERVE DR
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95678-1340
Practice Address - Country:US
Practice Address - Phone:916-782-7758
Practice Address - Fax:916-782-7770
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA30538207KA0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ7673ZMedicaid
CAA26142Medicare UPIN