Provider Demographics
NPI:1578526497
Name:KURUKULASURIYA, DAMASCENE SRIYAN (MD)
Entity Type:Individual
Prefix:
First Name:DAMASCENE
Middle Name:SRIYAN
Last Name:KURUKULASURIYA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:910 N COLLEGE AVE STE 4
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-4797
Mailing Address - Country:US
Mailing Address - Phone:636-642-1215
Mailing Address - Fax:573-234-4799
Practice Address - Street 1:910 N COLLEGE AVE STE 4
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-4797
Practice Address - Country:US
Practice Address - Phone:636-642-1215
Practice Address - Fax:573-234-4799
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMD114257207RG0300X
MO114257207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO152360034Medicare PIN