Provider Demographics
NPI:1770876641
Name:PERERA, THUSHANTHI SHANILA (MD)
Entity type:Individual
Prefix:
First Name:THUSHANTHI
Middle Name:SHANILA
Last Name:PERERA
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 1:815 HALLOCK AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-1244
Mailing Address - Country:US
Mailing Address - Phone:631-331-7267
Mailing Address - Fax:631-331-7289
Practice Address - Street 1:815 HALLOCK AVE
Practice Address - Street 2:SUITE A
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-1244
Practice Address - Country:US
Practice Address - Phone:631-331-7267
Practice Address - Fax:631-331-7289
Is Sole Proprietor?:No
Enumeration Date:2011-05-25
Last Update Date:2014-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY274085-1208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics