Provider Demographics
NPI:1295745743
Name:MAITHRI N. WEERASINGHE MD INC
Entity type:Organization
Organization Name:MAITHRI N. WEERASINGHE MD INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARCO
Authorized Official - Middle Name:A
Authorized Official - Last Name:ALFONZO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-953-8059
Mailing Address - Street 1:PO BOX 487
Mailing Address - Street 2:
Mailing Address - City:BARSTOW
Mailing Address - State:CA
Mailing Address - Zip Code:92312-0487
Mailing Address - Country:US
Mailing Address - Phone:760-953-8059
Mailing Address - Fax:
Practice Address - Street 1:716 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BARSTOW
Practice Address - State:CA
Practice Address - Zip Code:92311-2354
Practice Address - Country:US
Practice Address - Phone:760-256-6426
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-08
Last Update Date:2015-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA48518207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ01834ZMedicare ID - Type UnspecifiedPROVIDER NUMBER