Provider Demographics
NPI: | 1790095040 |
---|---|
Name: | JAYASEKERA, CHANNA R (MD, MS, MSC) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | CHANNA |
Middle Name: | R |
Last Name: | JAYASEKERA |
Suffix: | |
Gender: | M |
Credentials: | MD, MS, MSC |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 13400 E SHEA BLVD |
Mailing Address - Street 2: | |
Mailing Address - City: | SCOTTSDALE |
Mailing Address - State: | AZ |
Mailing Address - Zip Code: | 85259-5499 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 408-301-8000 |
Mailing Address - Fax: | 904-953-0115 |
Practice Address - Street 1: | 13400 E SHEA BLVD |
Practice Address - Street 2: | |
Practice Address - City: | SCOTTSDALE |
Practice Address - State: | AZ |
Practice Address - Zip Code: | 85259-5499 |
Practice Address - Country: | US |
Practice Address - Phone: | 408-301-8000 |
Practice Address - Fax: | 904-953-0115 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2010-10-19 |
Last Update Date: | 2021-04-19 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
CA | A113689 | 207R00000X, 207RG0100X |
AZ | 63158 | 207RG0100X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207RG0100X | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
CA | A113689 | Other | MEDICAL BOARD OF CALIFORNIA |