Provider Demographics
NPI:1467458216
Name:PERERA, CHANNA (MD)
Entity type:Individual
Prefix:
First Name:CHANNA
Middle Name:
Last Name:PERERA
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 1:755 CAMPBELL AVE STE 3
Mailing Address - Street 2:
Mailing Address - City:WEST HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06516-3715
Mailing Address - Country:US
Mailing Address - Phone:203-937-1100
Mailing Address - Fax:203-937-1102
Practice Address - Street 1:755 CAMPBELL AVE STE 3
Practice Address - Street 2:
Practice Address - City:WEST HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06516-3715
Practice Address - Country:US
Practice Address - Phone:203-937-1100
Practice Address - Fax:203-937-1102
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-27
Last Update Date:2011-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT036182207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT00136823Medicaid
CT110194409OtherRAILROAD MEDICARE
CT708711OtherCONNECTICARE
CT010036182CT01OtherANTHEM BLUE SHIELD
CTP1013460OtherOXFORD
CT2026973OtherAETNA
CT0V7493OtherHEALTHNET
CT2026973OtherAETNA
CT0V7493OtherHEALTHNET