Provider Demographics
NPI:1336221233
Name:BASNAYAKE, KANISTA MENIKE (MD)
Entity Type:Individual
Prefix:DR
First Name:KANISTA
Middle Name:MENIKE
Last Name:BASNAYAKE
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 1:3 ESPLANADE DR
Mailing Address - Street 2:
Mailing Address - City:EAST PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-7905
Mailing Address - Country:US
Mailing Address - Phone:631-758-6773
Mailing Address - Fax:631-758-6773
Practice Address - Street 1:365 E MAIN ST
Practice Address - Street 2:SOUTH BROOKHAVEN HEALTH CENTER WEST
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-3145
Practice Address - Country:US
Practice Address - Phone:631-854-1281
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY189498207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYF40237Medicare UPIN