Provider Demographics
NPI:1790763654
Name:DHARMAGUNARATNE, CHRISETTE (MD)
Entity Type:Individual
Prefix:
First Name:CHRISETTE
Middle Name:
Last Name:DHARMAGUNARATNE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8877 HARRY HINES BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75235-1715
Mailing Address - Country:US
Mailing Address - Phone:214-393-2940
Mailing Address - Fax:214-393-2945
Practice Address - Street 1:5959 HARRY HINES BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75235-6234
Practice Address - Country:US
Practice Address - Phone:214-393-2940
Practice Address - Fax:214-393-2945
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-02
Last Update Date:2011-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK2891207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX5201761OtherAETNA
TX0084EGOtherBCBS
TX00136LMedicare PIN
TX0084EGOtherBCBS