Provider Demographics
NPI:1679684526
Name:PERERA, PHILLIPS JR (MD)
Entity Type:Individual
Prefix:DR
First Name:PHILLIPS
Middle Name:
Last Name:PERERA
Suffix:JR
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 1:300 PASTEUR DRIVE, ALWAY BUILDING, M121
Mailing Address - Street 2:DIVISION OF EMERGENCY MEDICINE, STANFORD UNIVERSITY
Mailing Address - City:STANFORD
Mailing Address - State:CA
Mailing Address - Zip Code:94305-2200
Mailing Address - Country:US
Mailing Address - Phone:650-725-9445
Mailing Address - Fax:650-723-0121
Practice Address - Street 1:300 PASTEUR DRIVE, ALWAY BUILDING, M121
Practice Address - Street 2:DIVISION OF EMERGENCY MEDICINE, STANFORD UNIVERSITY
Practice Address - City:STANFORD
Practice Address - State:CA
Practice Address - Zip Code:94305-2200
Practice Address - Country:US
Practice Address - Phone:650-725-9445
Practice Address - Fax:650-723-0121
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2012-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY206235207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01961191Medicaid
G96229Medicare UPIN
NY50C081Medicare ID - Type Unspecified