Provider Demographics
NPI:1427034917
Name:FERNANDO, JAYASIRI RAVINATH
Entity Type:Individual
Prefix:
First Name:JAYASIRI
Middle Name:RAVINATH
Last Name:FERNANDO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:907 W LINCOLN AVE
Mailing Address - Street 2:PO BOX 770
Mailing Address - City:CHARLESTON
Mailing Address - State:IL
Mailing Address - Zip Code:61920-2413
Mailing Address - Country:US
Mailing Address - Phone:217-345-2100
Mailing Address - Fax:217-345-8366
Practice Address - Street 1:907 W LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:IL
Practice Address - Zip Code:61920-2413
Practice Address - Country:US
Practice Address - Phone:217-345-2100
Practice Address - Fax:217-345-8366
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILL52066Medicare ID - Type Unspecified
C41851Medicare UPIN