Provider Demographics
NPI:1366426306
Name:JAYASEKARA, DEEPTHI KUMARA (MD)
Entity type:Individual
Prefix:
First Name:DEEPTHI
Middle Name:KUMARA
Last Name:JAYASEKARA
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 1:935 W FOOTHILL BLVD
Mailing Address - Street 2:
Mailing Address - City:CLAREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:91711-3304
Mailing Address - Country:US
Mailing Address - Phone:626-851-8880
Mailing Address - Fax:626-851-8001
Practice Address - Street 1:935 W FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:CLAREMONT
Practice Address - State:CA
Practice Address - Zip Code:91711-3304
Practice Address - Country:US
Practice Address - Phone:626-851-8880
Practice Address - Fax:626-851-8001
Is Sole Proprietor?:No
Enumeration Date:2005-12-02
Last Update Date:2020-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA69077207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA69077Medicaid
CAGR0059520Medicaid
CAH5906Medicare PIN
CAW15222Medicare PIN
CAGR0059520Medicaid
CACD865ZMedicare PIN
CABT289AMedicare PIN
CAA69077Medicaid
CACN978ZMedicare PIN