Provider Demographics
NPI:1457359291
Name:DE SILVA, KEERTHI R (MD)
Entity Type:Individual
Prefix:
First Name:KEERTHI
Middle Name:R
Last Name:DE SILVA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1141 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
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-13
Last Update Date:2008-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA30035174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A300350Medicaid
CA00A300350Medicaid
CAA84035Medicare UPIN