Provider Demographics
NPI:1356529440
Name:KEERTHI R DE SILVA, M.D., INC.
Entity type:Organization
Organization Name:KEERTHI R DE SILVA, M.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KEERTHI
Authorized Official - Middle Name:R
Authorized Official - Last Name:DESILVA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-515-0677
Mailing Address - Street 1:1141 W REDONDO BEACH BLVD
Mailing Address - Street 2:SUITE 107
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90247-3586
Mailing Address - Country:US
Mailing Address - Phone:310-515-0677
Mailing Address - Fax:310-515-5033
Practice Address - Street 1:1141 W REDONDO BEACH BLVD
Practice Address - Street 2:SUITE 107
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90247-3586
Practice Address - Country:US
Practice Address - Phone:310-515-0677
Practice Address - Fax:310-515-5033
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-31
Last Update Date:2008-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA30035174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A300350Medicaid
CA00A300350Medicaid
CAW21891Medicare PIN