Provider Demographics
NPI:1841258902
Name:SAMARASEKERA, NISAL K (MD)
Entity type:Individual
Prefix:DR
First Name:NISAL
Middle Name:K
Last Name:SAMARASEKERA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6320 W UNION HILLS DR STE A210
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-7212
Mailing Address - Country:US
Mailing Address - Phone:623-362-8866
Mailing Address - Fax:623-362-8867
Practice Address - Street 1:6320 W UNION HILLS DR STE A210
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-7212
Practice Address - Country:US
Practice Address - Phone:623-362-8866
Practice Address - Fax:623-362-8867
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2009-12-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ23001207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZG04709Medicare UPIN
AZZ21270Medicare PIN