Provider Demographics
NPI:1558488783
Name:JAYASUNDERA, VICTOR (RPT)
Entity Type:Individual
Prefix:
First Name:VICTOR
Middle Name:
Last Name:JAYASUNDERA
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23100 PROVIDENCE DR
Mailing Address - Street 2:SUITE 135
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-3646
Mailing Address - Country:US
Mailing Address - Phone:248-905-5180
Mailing Address - Fax:248-905-5181
Practice Address - Street 1:23100 PROVIDENCE DR
Practice Address - Street 2:SUITE 135
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-3646
Practice Address - Country:US
Practice Address - Phone:248-905-5180
Practice Address - Fax:248-905-5181
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2012-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501005927174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5501005927OtherSTATE LICENSE